MEDICARE: DOUGLAS LEE DIESEL CPO, LPO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	222Z00000X	Orthotist	255	TX
2	224P00000X	Prosthetist	255	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	531778	OTHER	TX	BCBS

General Provider Information

NPI Number	:	1164645156
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOUGLAS LEE DIESEL CPO, LPO

Provider Business Mailing Address
First Line	:	1411 W HOUSTON ST
Second Line	:
City	:	SHERMAN
State	:	TX
Zip	:	75092-7409
Country	:	US
Telephone Number	:	903-891-0230
Fax Number	:	903-891-8743

Provider Business Practice Location Address
First Line	:	1411 W HOUSTON ST
Second Line	:
City	:	SHERMAN
State	:	TX
Zip	:	75092-7409
Country	:	US
Telephone Number	:	903-891-0230
Fax Number	:	903-891-8743

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/10/2007
Last Update Date	:	02/25/2008

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