Healthcare Provider Details

I. General information

NPI: 1285603621
Provider Name (Legal Business Name): JERRY EDWARD DOUGLAS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 04/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15322 LAKESHORE DR SUITE 202
CLEARLAKE CA
95422-9814
US

IV. Provider business mailing address

333 LAWS AVE
UKIAH CA
95482-6540
US

V. Phone/Fax

Practice location:
  • Phone: 707-994-0303
  • Fax: 707-995-9447
Mailing address:
  • Phone: 707-472-3944
  • Fax: 707-468-0174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01032101A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC53653
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number53653
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: