Healthcare Provider Details

I. General information

NPI: 1497733893
Provider Name (Legal Business Name): STEVEN L. DOUGLAS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2006
Last Update Date: 02/18/2021
Certification Date: 02/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 N LINCOLN ST
EAST PRAIRIE MO
63845-1160
US

IV. Provider business mailing address

PO BOX 801143
KANSAS CITY MO
64180-1143
US

V. Phone/Fax

Practice location:
  • Phone: 573-649-3026
  • Fax: 573-649-5600
Mailing address:
  • Phone: 573-331-5583
  • Fax: 573-331-5079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD114557
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: