Provider Demographics
NPI:1871580498
Name:SPYRISON, DOUGLAS C (OD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:C
Last Name:SPYRISON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1705 DELHI ST
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52001-5934
Mailing Address - Country:US
Mailing Address - Phone:563-588-4651
Mailing Address - Fax:563-557-1073
Practice Address - Street 1:1705 DELHI ST
Practice Address - Street 2:
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52001-5934
Practice Address - Country:US
Practice Address - Phone:563-588-4651
Practice Address - Fax:563-557-1073
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1760152W00000X, 152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0185975Medicaid
IA18597Medicare PIN
IAT01071Medicare UPIN