Provider Demographics
NPI:1699964916
Name:DEW, DOUGLAS K (MD, MBA)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:K
Last Name:DEW
Suffix:
Gender:M
Credentials:MD, MBA
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 1459
Mailing Address - Street 2:
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32178-1459
Mailing Address - Country:US
Mailing Address - Phone:904-825-2737
Mailing Address - Fax:904-825-2303
Practice Address - Street 1:6050 SAINT JOHNS AVE
Practice Address - Street 2:SUTIE 3
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-6860
Practice Address - Country:US
Practice Address - Phone:904-825-2737
Practice Address - Fax:904-825-2303
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-23
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME51037174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL12829Medicare PIN