Provider Demographics
NPI:1942255906
Name:MINER, DOUGLAS CHARLES (OD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:CHARLES
Last Name:MINER
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 1:4820 E FAIRFIELD ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85205-5344
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1635 N GREENFIELD RD
Practice Address - Street 2:SUITE 136
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-4005
Practice Address - Country:US
Practice Address - Phone:480-219-2412
Practice Address - Fax:480-219-2843
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ641152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
116725OtherMEDICARE PTAN
T76734Medicare UPIN