Healthcare Provider Details

I. General information

NPI: 1689677544
Provider Name (Legal Business Name): DOUGLAS I CIFUENTES D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 10/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1103 VILLAGE SQUARE DR STE 100
PERRYSBURG OH
43551-1762
US

IV. Provider business mailing address

2200 JEFFERSON AVE 4TH FLOOR
TOLEDO OH
43604-7101
US

V. Phone/Fax

Practice location:
  • Phone: 419-872-3213
  • Fax: 419-872-9549
Mailing address:
  • Phone: 419-251-1963
  • Fax: 419-872-9549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number34-00-7147-C
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number02005184A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: