Provider Demographics
NPI:1457535908
Name:DOUGLAS GUTHRIE JR DPM
Entity type:Organization
Organization Name:DOUGLAS GUTHRIE JR DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:GUTHRIE
Authorized Official - Suffix:JR
Authorized Official - Credentials:DPM
Authorized Official - Phone:254-562-7999
Mailing Address - Street 1:3200 CREEKWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-1350
Mailing Address - Country:US
Mailing Address - Phone:254-562-7999
Mailing Address - Fax:
Practice Address - Street 1:514 S BONHAM ST
Practice Address - Street 2:SUITE B
Practice Address - City:MEXIA
Practice Address - State:TX
Practice Address - Zip Code:76667-3600
Practice Address - Country:US
Practice Address - Phone:254-562-7999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-19
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX00194261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00F140OtherBLUE CROSS BLUE SHIELD
TX4116830001Medicare NSC