Healthcare Provider Details

I. General information

NPI: 1780677906
Provider Name (Legal Business Name): DOUGLAS P CALVIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 02/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3925 N GATEWAY DR
APPLETON WI
54913-7863
US

IV. Provider business mailing address

3232 N BALLARD RD STE 200 ATTN: CREDENTIALING
APPLETON WI
54911-8804
US

V. Phone/Fax

Practice location:
  • Phone: 920-749-1171
  • Fax: 920-749-1172
Mailing address:
  • Phone: 920-749-9668
  • Fax: 920-734-5307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number13714
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number13714
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: