Healthcare Provider Details

I. General information

NPI: 1851686182
Provider Name (Legal Business Name): THOMAS G DOUGLAS NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2011
Last Update Date: 06/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 S HICKORY ST
MOUNT VERNON MO
65712-1407
US

IV. Provider business mailing address

2828 N NATIONAL AVE
SPRINGFIELD MO
65803-4306
US

V. Phone/Fax

Practice location:
  • Phone: 417-466-4110
  • Fax: 417-466-4255
Mailing address:
  • Phone: 417-837-4000
  • Fax: 417-875-4710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2011016629
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: