Provider Demographics
NPI:1255386637
Name:MANN, DOUGLAS L III
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:L
Last Name:MANN
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 6TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601-3115
Mailing Address - Country:US
Mailing Address - Phone:256-351-0040
Mailing Address - Fax:256-301-9449
Practice Address - Street 1:201 6TH AVE SE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601-3115
Practice Address - Country:US
Practice Address - Phone:256-351-0040
Practice Address - Fax:256-301-9449
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS918TA501152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U498711Medicare UPIN