MEDICARE: DR. GARY LEE DOUGLAS MD

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	207XP3100X	Pediatric Orthopaedic Surgery Physician	J6924	TX

General Provider Information

NPI Number	:	1205091683
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARY LEE DOUGLAS MD

Provider Business Mailing Address
First Line	:	4020 EDGEHILL RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76116-7325
Country	:	US
Telephone Number	:	817-377-3352
Fax Number	:

Provider Business Practice Location Address
First Line	:	4020 EDGEHILL RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76116-7325
Country	:	US
Telephone Number	:	817-377-3352
Fax Number	:

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

Provider Enumeration Date	:	07/24/2008
Last Update Date	:	07/24/2008

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