Basic Information
| Provider Information | |||||||||
| NPI: | 1396741633 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOOLIN | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15933 CLAYTON RD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | BALLWIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630112172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362004393 | ||||||||
| FaxNumber: | 6365270838 | ||||||||
| Practice Location | |||||||||
| Address1: | 417A RACETRACK RD NW | ||||||||
| Address2: | |||||||||
| City: | FORT WALTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325474600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8503158861 | ||||||||
| FaxNumber: | 8508642844 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2005 | ||||||||
| LastUpdateDate: | 08/03/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPC1405 | FL | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 593537436 | 01 | FL | TRICARE | OTHER | A11078 | 01 | EYEMED | OTHER | 19465 | 01 | FL | BLUECROSSBLUESHIELD | OTHER |