Provider Demographics
NPI:1750582326
Name:EBBINK, DOUGLAS (OPTICIAN)
Entity type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:
Last Name:EBBINK
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1808 VERDUGO BLVD
Mailing Address - Street 2:#120
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91208-1477
Mailing Address - Country:US
Mailing Address - Phone:818-952-1124
Mailing Address - Fax:818-952-3809
Practice Address - Street 1:1808 VERDUGO BLVD
Practice Address - Street 2:#120 VERDUGO OPTICAL
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91208-1477
Practice Address - Country:US
Practice Address - Phone:818-952-1124
Practice Address - Fax:818-952-3809
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD3290156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician