Healthcare Provider Details

I. General information

NPI: 1295958312
Provider Name (Legal Business Name): DOUGLAS S LISTER DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 SOUTH ST
FORT BRAGG CA
95437-5540
US

IV. Provider business mailing address

205 SOUTH ST
FORT BRAGG CA
95437-5540
US

V. Phone/Fax

Practice location:
  • Phone: 707-964-1251
  • Fax: 707-961-2722
Mailing address:
  • Phone: 707-964-1251
  • Fax: 707-961-2722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberE41920
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: