1679986277 NPI number — DR. STEPHANIE DOUGLAS M.D.

Table of content: KERRY SMITH SLP (NPI 1316723612)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679986277 NPI number — DR. STEPHANIE DOUGLAS M.D.

Organization/Personal Information

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

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:
1679986277
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/05/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
430 BROADWAY STREET, MC: 6342
Provider Second Line Business Mailing Address:
PAVILION C, 4TH FLOOR
Provider Business Mailing Address City Name:
REDWOOD CITY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94063-3132
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
650-721-7669
Provider Business Mailing Address Fax Number:
650-721-3470

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
450 BROADWAY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
REDWOOD CITY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94063-3132
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
650-723-5643
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/11/2014

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: 208100000X , with the licence number:  2021025372 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208D00000X , with the licence number: 01084127A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208D00000X , with the licence number: ETL-6027 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2081S0010X , with the licence number: 198522 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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