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General NPI Number Information
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NPI Number | 1144900572
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Entity Type | Individual
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Provider Name | MR. MYRON B DOUGLAS SR.
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Gender | Male
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Dates
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Enumeration Date | 07/20/2023
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Last Update Date | 07/20/2023
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Provider Practice Location Address
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Address Line | 406 BRUSHY BAYOU BLVD
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City | SHREVEPORT
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State | LA
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Zip | 71106-6900
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Country | US
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Telephone | 318-470-3585
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Fax |
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Provider Business Mailing Address
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Address Line | 406 BRUSHY BAYOU BLVD
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City | SHREVEPORT
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State | LA
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Zip | 71106-6900
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Country | US
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Telephone | 318-470-3585
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Fax |
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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 | 332900000X
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Taxonomy Name | Non-Pharmacy Dispensing Site
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License Number |
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License Number State | LA
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Taxonomy #2
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Taxonomy Code | 343900000X
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Taxonomy Name | Non-emergency Medical Transport (VAN)
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License Number |
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License Number State | LA
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