Provider Demographics
NPI:1548345663
Name:DOUGLAS, DREW DORAN (OD)
Entity type:Individual
Prefix:DR
First Name:DREW
Middle Name:DORAN
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8614 WESTWOOD CENTER DR FL 9
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-2442
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:4524 S BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-1305
Practice Address - Country:US
Practice Address - Phone:903-581-1530
Practice Address - Fax:903-534-8629
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5114152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX25286OtherOPTICARE CHIPS
TX83057EMedicare ID - Type UnspecifiedMEDICARE PROVICER
TX25286OtherOPTICARE CHIPS