Healthcare Provider Details

I. General information

NPI: 1316045974
Provider Name (Legal Business Name): MICHAL A DOUGLAS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 12/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 W 38TH ST BLDG. F
AUSTIN TX
78705-1121
US

IV. Provider business mailing address

711 W 38TH ST BLDG. F
AUSTIN TX
78705-1121
US

V. Phone/Fax

Practice location:
  • Phone: 512-458-6121
  • Fax: 512-452-9171
Mailing address:
  • Phone: 512-458-6121
  • Fax: 512-452-9171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberG2686
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: