Provider Demographics
NPI:1063406262
Name:DOUGLASS, PAUL LAWRENCE (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:LAWRENCE
Last Name:DOUGLASS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4441 ATLANTA RD SE STE 213
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-6442
Mailing Address - Country:US
Mailing Address - Phone:470-956-9480
Mailing Address - Fax:
Practice Address - Street 1:4441 ATLANTA RD SE STE 213
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-6442
Practice Address - Country:US
Practice Address - Phone:470-956-9480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-02
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA019205207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA060017368/CM0845OtherRAILROAD MEDICARE
GA00241788AMedicaid
GA00241788AMedicaid