Healthcare Provider Details

I. General information

NPI: 1407840911
Provider Name (Legal Business Name): JOHN T DOUGLAS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HIGHWAY 16
PALATKA FL
32178-0778
US

IV. Provider business mailing address

2729 SE 48TH AVE
OCALA FL
34471-6380
US

V. Phone/Fax

Practice location:
  • Phone: 386-326-7850
  • Fax:
Mailing address:
  • Phone: 352-266-5880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberARNP324902
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: