Healthcare Provider Details

I. General information

NPI: 1679576516
Provider Name (Legal Business Name): MARK JASON DOUGLAS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 11/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2880 DAUPHIN ST
MOBILE AL
36606-2457
US

IV. Provider business mailing address

2880 DAUPHIN ST
MOBILE AL
36606-2457
US

V. Phone/Fax

Practice location:
  • Phone: 251-473-1900
  • Fax: 251-470-8943
Mailing address:
  • Phone: 251-473-1900
  • Fax: 251-470-8943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number00020396
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: