Provider Demographics
NPI:1033111737
Name:DOUGLAS, ALBERT S (MD)
Entity Type:Individual
Prefix:
First Name:ALBERT
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 1:576 LINDEN BLVD
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-3016
Mailing Address - Country:US
Mailing Address - Phone:718-287-5100
Mailing Address - Fax:718-287-1848
Practice Address - Street 1:576 LINDEN BLVD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-3016
Practice Address - Country:US
Practice Address - Phone:718-287-5100
Practice Address - Fax:718-287-1848
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-11
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY139912174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00694995Medicaid
NY00694995Medicaid