Healthcare Provider Details

I. General information

NPI: 1053402826
Provider Name (Legal Business Name): DOUGLAS FLOYD FACKLER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

EVANSVILLE VA OUTPATIENT CLINIC 500 E. WALNUT
EVANSVILLE IN
47713
US

IV. Provider business mailing address

143 PENNYRILE DR
MADISONVILLE KY
42431-9219
US

V. Phone/Fax

Practice location:
  • Phone: 812-465-6202
  • Fax: 812-465-6201
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA00512
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: