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General NPI Number Information
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NPI Number | 1285603621
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Entity Type | Individual
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Provider Name | JERRY EDWARD DOUGLAS MD
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Gender | Male
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Dates
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Enumeration Date | 03/17/2006
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Last Update Date | 04/02/2018
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Provider Practice Location Address
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Address Line | 15322 LAKESHORE DR SUITE 202
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City | CLEARLAKE
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State | CA
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Zip | 95422-9814
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Country | US
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Telephone | 707-994-0303
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Fax | 707-995-9447
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Provider Business Mailing Address
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Address Line | 333 LAWS AVE
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City | UKIAH
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State | CA
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Zip | 95482-6540
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Country | US
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Telephone | 707-472-3944
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Fax | 707-468-0174
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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 | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 01032101A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | C53653
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 53653
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License Number State | CA
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