Healthcare Provider Details

I. General information

NPI: 1285126011
Provider Name (Legal Business Name): DIANE SEREX-DOUGAN, O.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2018
Last Update Date: 06/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7954 HARFORD RD
BALTIMORE MD
21234-5838
US

IV. Provider business mailing address

7954 HARFORD RD
BALTIMORE MD
21234-5838
US

V. Phone/Fax

Practice location:
  • Phone: 443-629-5459
  • Fax:
Mailing address:
  • Phone: 443-629-5459
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License NumberTAO849
License Number StateMD

VIII. Authorized Official

Name: DIANE R SEREX-DOUGAN
Title or Position: OPTOMETRIST
Credential: O.D.
Phone: 443-629-5459