Provider Demographics
NPI:1396760476
Name:DOUGLAS, DAVID (PAC)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 517
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65706-0517
Mailing Address - Country:US
Mailing Address - Phone:417-849-5072
Mailing Address - Fax:
Practice Address - Street 1:755 COWAN DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:MO
Practice Address - Zip Code:65536-4629
Practice Address - Country:US
Practice Address - Phone:417-532-2805
Practice Address - Fax:417-532-2865
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004022171363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202941OtherBC, HARTVILLE MEDICAL CEN
MO202943OtherBC, VALLEY MEDICAL CENTER
MO220024481Medicaid
MO000097195Medicare ID - Type UnspecifiedVALLEY MEDICAL CENTER
MO000097196Medicare ID - Type UnspecifiedHARTIVILLE MEDICAL CENTER
MO202941OtherBC, HARTVILLE MEDICAL CEN