MEDICARE: MICHAEL L DOUGLAS DC

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	111N00000X	Chiropractor	CH5191	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	70861	OTHER		BCBS

General Provider Information

NPI Number	:	1407853088
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL L DOUGLAS DC

Provider Business Mailing Address
First Line	:	4140 NW 12TH ST
Second Line	:
City	:	LAUDERHILL
State	:	FL
Zip	:	33313-5816
Country	:	US
Telephone Number	:	954-739-3331
Fax Number	:	954-792-4520

Provider Business Practice Location Address
First Line	:	4140 NW 12TH ST
Second Line	:
City	:	LAUDERHILL
State	:	FL
Zip	:	33313-5816
Country	:	US
Telephone Number	:	954-739-3331
Fax Number	:	954-792-4520

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

Provider Enumeration Date	:	06/28/2005
Last Update Date	:	11/08/2010

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Directions to “ MICHAEL L DOUGLAS DC” Practice Location

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