Provider Demographics
NPI:1861516239
Name:DOUGLAS, ROBERT DEAN
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:DEAN
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 307
Mailing Address - Street 2:12412 STAFFORD ST
Mailing Address - City:RAVENNA
Mailing Address - State:MI
Mailing Address - Zip Code:49451-0307
Mailing Address - Country:US
Mailing Address - Phone:231-853-6459
Mailing Address - Fax:231-853-6459
Practice Address - Street 1:12412 STAFFORD ST
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:MI
Practice Address - Zip Code:48451-0307
Practice Address - Country:US
Practice Address - Phone:231-853-6459
Practice Address - Fax:231-853-6459
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMI3937152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist