Healthcare Provider Details

I. General information

NPI: 1780666099
Provider Name (Legal Business Name): DOUGLAS ALLEN PRAGER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2005
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

374 SOUTHSHORE DR
LAKE WINNEBAGO MO
64034-9447
US

IV. Provider business mailing address

374 SOUTHSHORE DR
LAKE WINNEBAGO MO
64034-9447
US

V. Phone/Fax

Practice location:
  • Phone: 808-679-7672
  • Fax: 913-442-9023
Mailing address:
  • Phone: 808-679-7672
  • Fax: 913-442-9023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number109766
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207UN0902X
TaxonomyNuclear Imaging & Therapy Physician
License Number6587
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: