Provider Demographics
NPI:1104983808
Name:EKHOLM, DOUGLAS JACK (OD DOCTOR OF OPTOMET)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:JACK
Last Name:EKHOLM
Suffix:
Gender:M
Credentials:OD DOCTOR OF OPTOMET
Other - Prefix:
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Mailing Address - Street 1:5417 W SAGINAW HWY
Mailing Address - Street 2:CARE OF WALLACE OPTICIANS
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48917
Mailing Address - Country:US
Mailing Address - Phone:517-323-4027
Mailing Address - Fax:517-323-1807
Practice Address - Street 1:5417 W SAGINAW HWY
Practice Address - Street 2:CARE OF WALLACE OPTICIANS
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917
Practice Address - Country:US
Practice Address - Phone:517-323-4027
Practice Address - Fax:517-323-1807
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4901002272152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T71084Medicare UPIN
MION95640Medicare ID - Type Unspecified