Provider Demographics
NPI:1316989031
Name:ELEY, DOUGLAS RICHARD (OD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:RICHARD
Last Name:ELEY
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 1:9009 GATEWAY BLVD S
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79904-1215
Mailing Address - Country:US
Mailing Address - Phone:915-751-7760
Mailing Address - Fax:915-751-2376
Practice Address - Street 1:9009 GATEWAY BLVD S
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79904-1215
Practice Address - Country:US
Practice Address - Phone:915-751-7760
Practice Address - Fax:915-751-2376
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3778TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00E4400Medicaid
TX00E4400Medicaid
TXT13151Medicare UPIN