Provider Demographics
NPI:1306974464
Name:DOUGLAS, MARK L (DO)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:L
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:5098 WEST WASHINGTON ST
Mailing Address - Street 2:STE 408
Mailing Address - City:CROSS LANES
Mailing Address - State:WV
Mailing Address - Zip Code:25313-1419
Mailing Address - Country:US
Mailing Address - Phone:304-776-5594
Mailing Address - Fax:304-776-3521
Practice Address - Street 1:5098 WEST WASHINGTON ST
Practice Address - Street 2:STE 408
Practice Address - City:CROSS LANES
Practice Address - State:WV
Practice Address - Zip Code:25313-1419
Practice Address - Country:US
Practice Address - Phone:304-776-5594
Practice Address - Fax:304-776-3521
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2012-12-31
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WV1390207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001722523OtherBLUE CROSS BLUE SHIELD
WV0839644OtherMEDICARE PIN
WV4333567OtherAETNA
WV550773123OtherTAX ID
WV0839644OtherMEDICARE PIN
WV9311501Medicare ID - Type Unspecified