Healthcare Provider Details

I. General information

NPI: 1902329436
Provider Name (Legal Business Name): DONALD DOUGLAS,MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2017
Last Update Date: 07/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

261 RUCCIO WAY STE 190
LEXINGTON KY
40503-3566
US

IV. Provider business mailing address

733 CHINKAPIN DR STE 2
NICHOLASVILLE KY
40356-6023
US

V. Phone/Fax

Practice location:
  • Phone: 859-266-0404
  • Fax:
Mailing address:
  • Phone: 859-223-0721
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number26259
License Number StateKY

VIII. Authorized Official

Name: DR. DONALD R. DOUGLAS
Title or Position: PHYSICIAN
Credential: MD
Phone: 859-312-5751