Healthcare Provider Details

I. General information

NPI: 1750292264
Provider Name (Legal Business Name): MR. COREY EVERTT DOUGLAS SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6602 FIELDING CIR
COLORADO SPRINGS CO
80911-2931
US

IV. Provider business mailing address

6602 FIELDING CIR
COLORADO SPRINGS CO
80911-2931
US

V. Phone/Fax

Practice location:
  • Phone: 719-723-3028
  • Fax:
Mailing address:
  • Phone: 719-723-3028
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: