Healthcare Provider Details

I. General information

NPI: 1689634388
Provider Name (Legal Business Name): WADE G DOUGLAS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2006
Last Update Date: 08/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 CENTERVILLE ROAD SUITE 100
TALLAHASSEE FL
32308-3656
US

IV. Provider business mailing address

1401 CENTERVILLE ROAD SUITE 100
TALLAHASSEE FL
32308-3656
US

V. Phone/Fax

Practice location:
  • Phone: 850-877-5183
  • Fax: 850-656-1288
Mailing address:
  • Phone: 850-877-5183
  • Fax: 850-656-1288

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number21963
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME120744
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number21963
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: