Healthcare Provider Details

I. General information

NPI: 1588819221
Provider Name (Legal Business Name): DOUGLAS D. MAIR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2008
Last Update Date: 11/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1814 WALDEN LN SW
ROCHESTER MN
55902-0903
US

IV. Provider business mailing address

1814 WALDEN LN SW
ROCHESTER MN
55902-0903
US

V. Phone/Fax

Practice location:
  • Phone: 507-288-6850
  • Fax:
Mailing address:
  • Phone: 507-288-6850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number16279
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: