Provider Demographics
NPI:1144452459
Name:DOUGLAS, DIANA MARIE (OD)
Entity type:Individual
Prefix:DR
First Name:DIANA
Middle Name:MARIE
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:DIANA
Other - Middle Name:MARIE
Other - Last Name:KOESEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8133 E MARKET ST
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44484-2256
Mailing Address - Country:US
Mailing Address - Phone:330-856-6113
Mailing Address - Fax:
Practice Address - Street 1:1955 CELESTIAL DR NE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484-3982
Practice Address - Country:US
Practice Address - Phone:330-980-9067
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-20
Last Update Date:2009-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5534152W00000X
NC1979152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist