Healthcare Provider Details

I. General information

NPI: 1407199920
Provider Name (Legal Business Name): CHAD RICHARD DOUGLAS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2013
Last Update Date: 03/04/2020
Certification Date: 03/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 S 8TH ST
YAKIMA WA
98901-3020
US

IV. Provider business mailing address

PO BOX 2605
YAKIMA WA
98907-2605
US

V. Phone/Fax

Practice location:
  • Phone: 509-454-4143
  • Fax:
Mailing address:
  • Phone: 509-454-4143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberOP61034280
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number1199
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: