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NPI Code Detail

MEDICARE: ROBERT EDWARD DOUGLASS PT, ATC

MEDICARE: ROBERT EDWARD DOUGLASS PT, ATC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1225100000XPhysical Therapist006694CT
22255A2300XAthletic Trainer000174CT

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1006694OTHERCTPHYSICAL THERAPY LICENSE
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3000174OTHERCTATC LICENSE

General Provider Information

NPI Number : 1134281587
Entity Type Code : Individual
Provider Name (Legal Business Name) : ROBERT EDWARD DOUGLASS PT, ATC
Provider Business Mailing Address
First Line : 22 TOMPKINS ST
Second Line :
City : WATERBURY
State : CT
Zip : 06708-1458
Country : US
Telephone Number : 203-419-0381
Fax Number : 203-419-0389
Provider Business Practice Location Address
First Line : 22 TOMPKINS ST
Second Line :
City : WATERBURY
State : CT
Zip : 06708-1458
Country : US
Telephone Number : 203-419-0381
Fax Number : 203-419-0389
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/14/2006
Last Update Date : 03/08/2013

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