=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255417416
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DOUGLAS GEORGE BAILES DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/31/2006
-----------------------------------------------------
Last Update Date | 05/19/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4344 WEST BELL RD # 101
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-938-1401
-----------------------------------------------------
Fax | 602-938-3420
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4344 WEST BELL RD # 101
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-938-1401
-----------------------------------------------------
Fax | 602-938-3420
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 2449
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------