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NPI Code Detail

MEDICARE: DR. DOUGLAS STEPHEN WIERSMA O.D.

MEDICARE: DR. DOUGLAS STEPHEN WIERSMA O.D.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1152W00000XOptometrist6168OH

General Provider Information

NPI Number : 1518212539
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. DOUGLAS STEPHEN WIERSMA O.D.
Provider Business Mailing Address
First Line : 29885 SEQUOIA TRL
Second Line :
City : WESTLAKE
State : OH
Zip : 44145-5153
Country : US
Telephone Number : 440-376-1690
Fax Number :
Provider Business Practice Location Address
First Line : 1261 W ROYALTON RD
Second Line :
City : BROADVIEW HEIGHTS
State : OH
Zip : 44147-2407
Country : US
Telephone Number : 440-526-7070
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/16/2012
Last Update Date : 05/19/2023

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