Provider Demographics
NPI:1295774719
Name:WEST, DOUGLAS BRIAN (OD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:BRIAN
Last Name:WEST
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 1:1545 FORT HARRISON RD
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47804-1332
Mailing Address - Country:US
Mailing Address - Phone:812-460-0520
Mailing Address - Fax:812-460-0407
Practice Address - Street 1:1545 FORT HARRISON RD
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47804-1332
Practice Address - Country:US
Practice Address - Phone:812-460-0520
Practice Address - Fax:812-460-0407
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2010-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002092152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100251250Medicaid
607670Medicare ID - Type Unspecified
U57204Medicare UPIN