1366499675 NPI number — DONALD G DOUGLAS MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366499675 NPI number — DONALD G DOUGLAS MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

DOUGLAS

Provider First Name:

DONALD

Provider Middle Name:

G

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

M

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:

1366499675

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

07/09/2007

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

705 PLEASANT AVE S

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

PARK RAPIDS

Provider Business Mailing Address State Name:

MN

Provider Business Mailing Address Postal Code:

56470-1440

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

218-732-2800

Provider Business Mailing Address Fax Number:

218-732-2857

Provider First Line Business Practice Location Address:

705 PLEASANT AVE S

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

PARK RAPIDS

Provider Business Practice Location Address State Name:

MN

Provider Business Practice Location Address Postal Code:

56470-1440

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

218-732-2800

Provider Business Practice Location Address Fax Number:

218-732-2857

Provider Enumeration Date:

05/30/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 2085R0202X , with the licence number:  24647 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 12915 . This is a "NDBS #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 5154 . This is a "SIOUX VALLEY #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: HP25735 . This is a "HEALTHPARTNERS #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 126482 . This is a "UCARE #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 18686 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
• Identifier: 765067 . This is a "AMERICA'S PPO/ARAZ #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 8T818DO . This is a "MNBS #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 13026 . This is a "NDBS #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: FS9041015681 . This is a "PREFERRED ONE #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 1600863 . This is a "MEDICA #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: MN200003 . This is a "LHS/BANNERHEALTH #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".