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General NPI Number Information
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NPI Number | 1063801678
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Entity Type | Individual
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Provider Name | SAMUEL DOUGLASS DO
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Gender | Male
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Dates
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Enumeration Date | 01/20/2015
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Last Update Date | 04/18/2025
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Provider Practice Location Address
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Address Line | 1055 N CURTIS RD
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City | BOISE
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State | ID
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Zip | 83706-1309
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Country | US
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Telephone | 208-367-2121
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Fax | 706-596-6720
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Provider Business Mailing Address
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Address Line | 877 W MAIN ST STE 603
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City | BOISE
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State | ID
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Zip | 83702-6070
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Country | US
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Telephone | 208-954-8070
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Fax | 208-954-8073
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | OP61322937
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | DO219310
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License Number State | OR
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Taxonomy #3
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 1539
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License Number State | NE
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Taxonomy #4
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | OC-0433
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License Number State | ID
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