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General NPI Number Information
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NPI Number | 1396765251
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Entity Type | Individual
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Provider Name | W DOUGLAS BACK MD
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Gender | Male
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Dates
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Enumeration Date | 07/20/2006
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Last Update Date | 05/05/2008
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Provider Practice Location Address
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Address Line | 715 SHAKER DRIVE SUITE 120
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City | LEXINGTON
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State | KY
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Zip | 40504-3674
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Country | US
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Telephone | 859-278-8443
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Fax |
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Provider Business Mailing Address
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Address Line | 715 SHAKER DRIVE SUITE 120
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City | LEXINGTON
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State | KY
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Zip | 40504-3674
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Country | US
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Telephone | 859-278-8443
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Fax |
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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 | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | 21381
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License Number State | KY
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