Healthcare Provider Details

I. General information

NPI: 1154984862
Provider Name (Legal Business Name): EDWARD DOUGLAS II
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2019
Last Update Date: 04/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 HARRISON AVE
BOSTON MA
02118-4001
US

IV. Provider business mailing address

850 HARRISON AVE
BOSTON MA
02118-4001
US

V. Phone/Fax

Practice location:
  • Phone: 617-414-4722
  • Fax: 617-414-5520
Mailing address:
  • Phone: 617-414-4722
  • Fax: 617-414-5520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License Number2084B0040X
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: