1306974464 NPI number — DR. MARK L DOUGLAS DO

Table of content: DR. MARK L DOUGLAS DO (NPI 1306974464)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306974464 NPI number — DR. MARK L DOUGLAS DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOUGLAS
Provider First Name:
MARK
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1306974464
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/31/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5098 WEST WASHINGTON ST
Provider Second Line Business Mailing Address:
STE 408
Provider Business Mailing Address City Name:
CROSS LANES
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25313-1419
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-776-5594
Provider Business Mailing Address Fax Number:
304-776-3521

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5098 WEST WASHINGTON ST
Provider Second Line Business Practice Location Address:
STE 408
Provider Business Practice Location Address City Name:
CROSS LANES
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25313-1419
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-776-5594
Provider Business Practice Location Address Fax Number:
304-776-3521
Provider Enumeration Date:
03/01/2007

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: 207R00000X , with the licence number:  1390 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 001722523 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 0839644 . This is a "MEDICARE PIN" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 4333567 . This is a "AETNA" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 550773123 . This is a "TAX ID" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".




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