Healthcare Provider Details

I. General information

NPI: 1003871815
Provider Name (Legal Business Name): DOUGLAS W KINGMA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 05/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

448 CAROTHERS PARKWAY SUITE 310
FRANKLIN TN
37067
US

IV. Provider business mailing address

2004 HAYES ST STE 800
NASHVILLE TN
37203-2659
US

V. Phone/Fax

Practice location:
  • Phone: 615-986-4330
  • Fax: 615-550-4320
Mailing address:
  • Phone: 615-514-6963
  • Fax: 615-986-0560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License NumberMD430689
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License Number4301081425
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code207ZH0000X
TaxonomyHematology (Pathology) Physician
License Number25MA08843800
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number17073
License Number StateOK
# 5
Primary TaxonomyY
Taxonomy Code207ZH0000X
TaxonomyHematology (Pathology) Physician
License Number46486
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: