Healthcare Provider Details

I. General information

NPI: 1457734097
Provider Name (Legal Business Name): DOUGLAS INTERNAL MEDICINE P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2015
Last Update Date: 07/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 OCILLA RD
DOUGLAS GA
31533-2206
US

IV. Provider business mailing address

306 WESTSIDE DR
DOUGLAS GA
31533-3530
US

V. Phone/Fax

Practice location:
  • Phone: 912-383-7826
  • Fax: 912-383-7299
Mailing address:
  • Phone: 912-383-7826
  • Fax: 912-383-7299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036457
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN098350
License Number StateGA

VIII. Authorized Official

Name: DR. JAMES STAN SINCLAIR
Title or Position: OWNER
Credential: M.D.
Phone: 912-383-7826