Healthcare Provider Details

I. General information

NPI: 1396372694
Provider Name (Legal Business Name): DONTRE M DOUSE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2020
Last Update Date: 03/25/2026
Certification Date: 03/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 KENT RD STE 2
TIFTON GA
31794-1697
US

IV. Provider business mailing address

PO BOX 2650
TIFTON GA
31793-2650
US

V. Phone/Fax

Practice location:
  • Phone: 229-353-4368
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number104748
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number104748
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number30873
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number69872
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: