Provider Demographics
NPI:1063801678
Name:DOUGLASS, SAMUEL (DO)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:DOUGLASS
Suffix:
Gender:
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:877 W MAIN ST STE 603
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-6070
Mailing Address - Country:US
Mailing Address - Phone:208-954-8070
Mailing Address - Fax:208-954-8073
Practice Address - Street 1:1055 N CURTIS RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1309
Practice Address - Country:US
Practice Address - Phone:208-367-2121
Practice Address - Fax:706-596-6720
Is Sole Proprietor?:No
Enumeration Date:2015-01-20
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAOP613229372085R0202X
ORDO2193102085R0202X
NE15392085R0202X
IDOC-04332085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology