Healthcare Provider Details

I. General information

NPI: 1730615626
Provider Name (Legal Business Name): SASHA RENEE DOUGLAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 07/21/2025
Certification Date: 07/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 WOODLAND ST
HARTFORD CT
06105-1208
US

IV. Provider business mailing address

3 MORNINGSIDE CT
AVON CT
06001-3314
US

V. Phone/Fax

Practice location:
  • Phone: 860-714-6318
  • Fax: 860-714-9990
Mailing address:
  • Phone: 267-261-1764
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number80300
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: