Healthcare Provider Details

I. General information

NPI: 1720982879
Provider Name (Legal Business Name): MARTIN DOUGLAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13153 GREENBRIAR
WILLIS TX
77318-5771
US

IV. Provider business mailing address

13153 GREENBRIAR
WILLIS TX
77318-5771
US

V. Phone/Fax

Practice location:
  • Phone: 936-522-6805
  • Fax:
Mailing address:
  • Phone: 936-522-6805
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146L00000X
TaxonomyParamedic
License Number147124
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: