Provider Demographics
NPI:1306913884
Name:DOUGLASS, TIMOTHY DEEGAN (DC)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:DEEGAN
Last Name:DOUGLASS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4421 COMMONS DR E
Mailing Address - Street 2:SUITE B-105
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-3484
Mailing Address - Country:US
Mailing Address - Phone:850-650-6789
Mailing Address - Fax:850-650-6790
Practice Address - Street 1:4421 COMMONS DR E
Practice Address - Street 2:SUITE B-105
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-3484
Practice Address - Country:US
Practice Address - Phone:850-650-6789
Practice Address - Fax:850-650-6790
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH9683111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH8516111OtherCIGNA
NH0509581Y0NH01OtherANTHEM BLUE CROSSBLUE SHI
NH0509581Y0NH01OtherANTHEM BLUE CROSSBLUE SHI
NHRE6972Medicare ID - Type Unspecified