=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578786570
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DOUGLAS R POMEROY PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 250 CUSHMAN ST SUITE 2 F
-----------------------------------------------------
City | FAIRBANKS
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99701-4640
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-457-1744
-----------------------------------------------------
Fax | 907-457-3422
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3288 PLATO WAY
-----------------------------------------------------
City | NORTH POLE
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99705-7427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-488-1263
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 332
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------