Healthcare Provider Details

I. General information

NPI: 1538901830
Provider Name (Legal Business Name): RAYMOND DOUGLAS, M.D., PHD A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2024
Last Update Date: 06/10/2024
Certification Date: 06/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

653 N TOWN CENTER DR STE 512
LAS VEGAS NV
89144-0519
US

IV. Provider business mailing address

653 N TOWN CENTER DR STE 512
LAS VEGAS NV
89144-0519
US

V. Phone/Fax

Practice location:
  • Phone: 310-636-8757
  • Fax: 310-636-8758
Mailing address:
  • Phone: 310-636-8757
  • Fax: 310-363-8758

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: RAYMOND S DOUGLAS
Title or Position: PRESIDENT
Credential: MD
Phone: 310-363-8757