Provider Demographics
NPI:1487150165
Name:DOUGLAS, TAYLOR LEE (OD)
Entity type:Individual
Prefix:DR
First Name:TAYLOR
Middle Name:LEE
Last Name:DOUGLAS
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 1:208 E SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:HOUGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:49931-2010
Mailing Address - Country:US
Mailing Address - Phone:269-806-5577
Mailing Address - Fax:
Practice Address - Street 1:900 W MEM DR
Practice Address - Street 2:
Practice Address - City:HOUGHTON
Practice Address - State:MI
Practice Address - Zip Code:49931
Practice Address - Country:US
Practice Address - Phone:906-487-9767
Practice Address - Fax:906-487-9380
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-02
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901005117152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist