1336182914 NPI number — DR. GEORGE M DOUGLASS JR. MD

Table of content: DR. GEORGE M DOUGLASS JR. MD (NPI 1336182914)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336182914 NPI number — DR. GEORGE M DOUGLASS JR. MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOUGLASS
Provider First Name:
GEORGE
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
MD
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:
1336182914
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/03/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17355 BOONES FERRY RD
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
LAKE OSWEGO
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97035-5202
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-344-6445
Provider Business Mailing Address Fax Number:
503-344-6852

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17355 BOONES FERRY RD
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
LAKE OSWEGO
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97035-5202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-344-6445
Provider Business Practice Location Address Fax Number:
503-344-6852
Provider Enumeration Date:
06/13/2006

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: 207PS0010X , with the licence number:  MD22100 , 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: 240052 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8942008 . This is a "WA CRIME VICTIMS" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00350187 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 210868 . This is a "WA L & I" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8244444 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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