=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922071083
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JON C DOUGLAS AUD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2006
-----------------------------------------------------
Last Update Date | 08/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4202 E FOWLER AVE
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33620-8000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-821-8038
-----------------------------------------------------
Fax | 813-974-0483
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 917770
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32891-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-821-8038
-----------------------------------------------------
Fax | 813-974-0483
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 231H00000X
-----------------------------------------------------
Taxonomy Name | Audiologist
-----------------------------------------------------
License Number | 500-156
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 231H00000X
-----------------------------------------------------
Taxonomy Name | Audiologist
-----------------------------------------------------
License Number | AY2811
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------