Provider Demographics
NPI:1407679616
Name:DOUGLAS, DEMARCUS
Entity type:Individual
Prefix:
First Name:DEMARCUS
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 HIGHWAY 138
Mailing Address - Street 2:
Mailing Address - City:MERCER
Mailing Address - State:TN
Mailing Address - Zip Code:38392-7330
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1169 S DUPREE AVE
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38012-3260
Practice Address - Country:US
Practice Address - Phone:731-780-3011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-05
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
15229225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist