Provider Demographics
NPI:1346252442
Name:DOUGLAS, AARON S (MD)
Entity type:Individual
Prefix:
First Name:AARON
Middle Name:S
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 1:3916 N INTERTECH CT
Mailing Address - Street 2:ATTN: ADMINISTRATION
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-6956
Mailing Address - Country:US
Mailing Address - Phone:920-996-1000
Mailing Address - Fax:920-996-1050
Practice Address - Street 1:3916 N INTERTECH CT
Practice Address - Street 2:ATTN: ADMINISTRATION
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-6956
Practice Address - Country:US
Practice Address - Phone:920-996-1000
Practice Address - Fax:920-996-1050
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI49481207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34892200Medicaid
WI34892200Medicaid