=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467601872
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHEAST EYECARE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/10/2008
-----------------------------------------------------
Last Update Date | 01/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 955 BROADWAY
-----------------------------------------------------
City | BANGOR
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-990-4388
-----------------------------------------------------
Fax | 207-947-9241
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 955 BROADWAY
-----------------------------------------------------
City | BANGOR
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-990-4388
-----------------------------------------------------
Fax | 207-947-9241
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. DAVID T DOUGLASS
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 207-990-4388
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPT797
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------