Healthcare Provider Details

I. General information

NPI: 1215071733
Provider Name (Legal Business Name): DOUGLAS KENT GRAEBE O. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 WASHINGTON AVE
WHEELING WV
26003-6241
US

IV. Provider business mailing address

40 WILLIAMSBURG CIR
WHEELING WV
26003-5525
US

V. Phone/Fax

Practice location:
  • Phone: 740-695-3822
  • Fax: 740-695-3822
Mailing address:
  • Phone: 304-242-1145
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number682-D
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: