MEDICARE: KEVIN ANDREW DOUGLAS DPM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	213ES0103X	Foot & Ankle Surgery Podiatrist	N007168	NY

General Provider Information

NPI Number	:	1174020598
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEVIN ANDREW DOUGLAS DPM

Provider Business Mailing Address
First Line	:	1000 MONTAUK HWY
Second Line	:
City	:	WEST ISLIP
State	:	NY
Zip	:	11795-4927
Country	:	US
Telephone Number	:
Fax Number	:	631-376-3420

Provider Business Practice Location Address
First Line	:	100 MIDDLE COUNTRY RD
Second Line	:
City	:	CORAM
State	:	NY
Zip	:	11727-4412
Country	:	US
Telephone Number	:	631-696-9636
Fax Number	:	631-696-9635

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/11/2018
Last Update Date	:	06/06/2022

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Directions to “ KEVIN ANDREW DOUGLAS DPM” Practice Location

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