Healthcare Provider Details

I. General information

NPI: 1316175797
Provider Name (Legal Business Name): JOHN ALLEN DOUGLAS III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2009
Last Update Date: 07/31/2023
Certification Date: 07/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3805 CHEROKEE ST NW
KENNESAW GA
30144-2085
US

IV. Provider business mailing address

3805 CHEROKEE ST NW
KENNESAW GA
30144-2085
US

V. Phone/Fax

Practice location:
  • Phone: 770-426-5666
  • Fax: 770-420-1794
Mailing address:
  • Phone: 770-426-5666
  • Fax: 770-420-1794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD74188
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number72824
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: