Healthcare Provider Details

I. General information

NPI: 1710926860
Provider Name (Legal Business Name): DAVID WAYMON DOUGLAS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 11/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 TRILLIUM WAY
CORBIN KY
40701-8426
US

IV. Provider business mailing address

423 CEDAR RIDGE DR
LONDON KY
40744-7446
US

V. Phone/Fax

Practice location:
  • Phone: 606-528-1212
  • Fax:
Mailing address:
  • Phone: 606-878-9020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number25732
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: