Provider Demographics
NPI:1194796011
Name:DOUGLAS, JOE (MD)
Entity type:Individual
Prefix:
First Name:JOE
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JOSEPH
Other - Middle Name:
Other - Last Name:DOUGLAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:200 MAINE
Mailing Address - Street 2:SUITE A
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66044-1368
Mailing Address - Country:US
Mailing Address - Phone:785-843-9192
Mailing Address - Fax:785-856-9191
Practice Address - Street 1:200 MAINE
Practice Address - Street 2:SUITE A
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66044-1368
Practice Address - Country:US
Practice Address - Phone:785-843-9192
Practice Address - Fax:785-856-9191
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04178152084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100097940AMedicaid
D17353Medicare UPIN