Provider Demographics
NPI:1396765251
Name:BACK, W DOUGLAS (MD)
Entity type:Individual
Prefix:
First Name:W DOUGLAS
Middle Name:
Last Name:BACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:WAYNE
Other - Middle Name:DOUGLAS
Other - Last Name:BACK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:715 SHAKER DRIVE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-3674
Mailing Address - Country:US
Mailing Address - Phone:859-278-8443
Mailing Address - Fax:
Practice Address - Street 1:715 SHAKER DRIVE
Practice Address - Street 2:SUITE 120
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-3674
Practice Address - Country:US
Practice Address - Phone:859-278-8443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY21381207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1391801Medicare ID - Type Unspecified
KYC78375Medicare UPIN