Healthcare Provider Details

I. General information

NPI: 1033105044
Provider Name (Legal Business Name): DOUGLAS A DEAETT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/26/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 MASCOMA ST
LEBANON NH
03766-2647
US

IV. Provider business mailing address

125 MASCOMA ST
LEBANON NH
03766-2647
US

V. Phone/Fax

Practice location:
  • Phone: 603-448-3121
  • Fax: 603-448-7462
Mailing address:
  • Phone: 603-448-3121
  • Fax: 603-448-7462

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number5988
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: