Provider Demographics
NPI:1285603621
Name:DOUGLAS, JERRY EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:EDWARD
Last Name:DOUGLAS
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 1:333 LAWS AVE
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-6540
Mailing Address - Country:US
Mailing Address - Phone:707-472-3944
Mailing Address - Fax:707-468-0174
Practice Address - Street 1:15322 LAKESHORE DR
Practice Address - Street 2:SUITE 202
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95422-9814
Practice Address - Country:US
Practice Address - Phone:707-994-0303
Practice Address - Fax:707-995-9447
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01032101A207Q00000X
CAC53653207Q00000X
CA53653207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200100490Medicaid
IN000000190581OtherANTHEM PROVIDER NUMBER
IN162528OtherPHCS PID NUMBER
IN11484440OtherCAQH NUMBER
IND94545Medicare UPIN
IN815500M2Medicare PIN
IN200100490Medicaid
IN162528OtherPHCS PID NUMBER
IN080135076Medicare PIN