Provider Demographics
NPI:1316900756
Name:DOUD, SANDRA L (OD)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:L
Last Name:DOUD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5477 W CLARK RD
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-1102
Mailing Address - Country:US
Mailing Address - Phone:734-434-6000
Mailing Address - Fax:734-434-7005
Practice Address - Street 1:5477 W CLARK RD
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1102
Practice Address - Country:US
Practice Address - Phone:734-434-6000
Practice Address - Fax:734-434-7005
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003116152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIT33455Medicare UPIN
MIOM50830Medicare ID - Type Unspecified
MI1975829Medicare ID - Type Unspecified