Healthcare Provider Details

I. General information

NPI: 1679986277
Provider Name (Legal Business Name): STEPHANIE DOUGLAS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2014
Last Update Date: 09/05/2024
Certification Date: 09/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 BROADWAY ST
REDWOOD CITY CA
94063-3132
US

IV. Provider business mailing address

430 BROADWAY STREET, MC: 6342 PAVILION C, 4TH FLOOR
REDWOOD CITY CA
94063-3132
US

V. Phone/Fax

Practice location:
  • Phone: 650-723-5643
  • Fax:
Mailing address:
  • Phone: 650-721-7669
  • Fax: 650-721-3470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number2021025372
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number01084127A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberETL-6027
License Number StateMA
# 4
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number198522
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: