Basic Information
| Provider Information | |||||||||
| NPI: | 1861431207 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOUGLAS | ||||||||
| FirstName: | ANNETTE | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | AKINWANDE | ||||||||
| OtherFirstName: | ANNETTE | ||||||||
| OtherMiddleName: | C | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 11995 SINGLETREE LN | ||||||||
| Address2: | STE 500 | ||||||||
| City: | EDEN PRAIRIE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553445347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9525951301 | ||||||||
| FaxNumber: | 6122944903 | ||||||||
| Practice Location | |||||||||
| Address1: | 8714 SARGENT CREEK LN | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462561376 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9525951100 | ||||||||
| FaxNumber: | 6122944903 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 08/31/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0700X | 01056651 | IN | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085R0202X | 01056651 | IN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.