Basic Information
| Provider Information | |||||||||
| NPI: | 1366499675 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOUGLAS | ||||||||
| FirstName: | DONALD | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 705 PLEASANT AVE S | ||||||||
| Address2: | |||||||||
| City: | PARK RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564701440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187322800 | ||||||||
| FaxNumber: | 2187322857 | ||||||||
| Practice Location | |||||||||
| Address1: | 705 PLEASANT AVE S | ||||||||
| Address2: | |||||||||
| City: | PARK RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564701440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187322800 | ||||||||
| FaxNumber: | 2187322857 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 24647 | MN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 12915 | 01 | MN | NDBS # | OTHER | 5154 | 01 | MN | SIOUX VALLEY # | OTHER | HP25735 | 01 | MN | HEALTHPARTNERS # | OTHER | 126482 | 01 | MN | UCARE # | OTHER | 18686 | 05 | MN | MEDICAID | 765067 | 01 | MN | AMERICA'S PPO/ARAZ # | OTHER | 8T818DO | 01 | MN | MNBS # | OTHER | 13026 | 01 | MN | NDBS # | OTHER | FS9041015681 | 01 | MN | PREFERRED ONE # | OTHER | 1600863 | 01 | MN | MEDICA # | OTHER | MN200003 | 01 | MN | LHS/BANNERHEALTH # | OTHER |