Healthcare Provider Details

I. General information

NPI: 1881199776
Provider Name (Legal Business Name): KRISTA MARIE DOUGLASS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARIE DOUGLASS

II. Dates (important events)

Enumeration Date: 03/24/2018
Last Update Date: 01/21/2025
Certification Date: 01/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 W CARSON ST
TORRANCE CA
90502-2004
US

IV. Provider business mailing address

1000 W CARSON ST
TORRANCE CA
90502-2059
US

V. Phone/Fax

Practice location:
  • Phone: 424-306-4061
  • Fax:
Mailing address:
  • Phone: 424-306-4061
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License NumberA164649
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: