Provider Demographics
NPI:1386335214
Name:DOUGLAS, CHRISTOPHER MICHAEL POPHAM (LDO)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:MICHAEL POPHAM
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2510 REDMOND CIR NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1913
Mailing Address - Country:US
Mailing Address - Phone:706-236-9960
Mailing Address - Fax:706-236-9215
Practice Address - Street 1:2510 REDMOND CIR NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1913
Practice Address - Country:US
Practice Address - Phone:706-236-9960
Practice Address - Fax:706-236-9215
Is Sole Proprietor?:No
Enumeration Date:2023-05-19
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALDO002272156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician