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General NPI Number Information
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NPI Number | 1104983808
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Entity Type | Individual
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Provider Name | DOUGLAS JACK EKHOLM OD DOCTOR OF OPTOMET
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Gender | Male
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Dates
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Enumeration Date | 01/02/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 5417 W SAGINAW HWY CARE OF WALLACE OPTICIANS
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City | LANSING
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State | MI
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Zip | 48917
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Country | US
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Telephone | 517-323-4027
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Fax | 517-323-1807
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Provider Business Mailing Address
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Address Line | 5417 W SAGINAW HWY CARE OF WALLACE OPTICIANS
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City | LANSING
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State | MI
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Zip | 48917
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Country | US
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Telephone | 517-323-4027
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Fax | 517-323-1807
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 4901002272
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License Number State | MI
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