Provider Demographics
NPI:1104883636
Name:GARBIG, DOUGLAS JOHN (OD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:JOHN
Last Name:GARBIG
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 1:1400 GLORIA TERRELL DR
Mailing Address - Street 2:SUITE H
Mailing Address - City:WILDER
Mailing Address - State:KY
Mailing Address - Zip Code:41076-9188
Mailing Address - Country:US
Mailing Address - Phone:859-441-3400
Mailing Address - Fax:859-572-4822
Practice Address - Street 1:1400 GLORIA TERRELL DR
Practice Address - Street 2:SUITE H
Practice Address - City:WILDER
Practice Address - State:KY
Practice Address - Zip Code:41076-9188
Practice Address - Country:US
Practice Address - Phone:859-441-3400
Practice Address - Fax:859-572-4822
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1108DT152W00000X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77011088Medicaid
KY000000184811OtherANTHEM PIN #
KY0004395284OtherAETNA
KY410042536OtherMEDICARE RAILROAD RETIREMENT BOARD
KY00498001Medicare PIN
KY77011088Medicaid
KY0470570001Medicare NSC