1952527871 NPI number — DR. BEN HAROLD DOUGLAS II M.D.

Table of content: MARY E MATERNA (NPI 1295248201)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952527871 NPI number — DR. BEN HAROLD DOUGLAS II M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOUGLAS
Provider First Name:
BEN
Provider Middle Name:
HAROLD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
II
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1952527871
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/15/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1011 THIRD ST
Provider Second Line Business Mailing Address:
BAY OCEAN MEDICAL, P.C.
Provider Business Mailing Address City Name:
TILLAMOOK
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97141-8292
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-842-7533
Provider Business Mailing Address Fax Number:
503-842-9636

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 3RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TILLAMOOK
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97141-3402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-842-7533
Provider Business Practice Location Address Fax Number:
503-842-9636
Provider Enumeration Date:
04/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207QA0505X , with the licence number:  MD19528 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1952527871 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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