Basic Information
| Provider Information | |||||||||
| NPI: | 1396760476 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOUGLAS | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | P.A.C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2580 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658012580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178294620 | ||||||||
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| Practice Location | |||||||||
| Address1: | 904 S PINE ST | ||||||||
| Address2: | |||||||||
| City: | RICHLAND | ||||||||
| State: | MO | ||||||||
| PostalCode: | 655567393 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737652956 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 02/14/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2004022171 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 202941 | 01 | MO | BC, HARTVILLE MEDICAL CEN | OTHER | 202943 | 01 | MO | BC, VALLEY MEDICAL CENTER | OTHER |