Provider Demographics
NPI:1033145164
Name:EDGREN, DOUGLAS W (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:W
Last Name:EDGREN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:WILLIAM
Other - Middle Name:
Other - Last Name:EDGREN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1331 PRAIRIE AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-4867
Mailing Address - Country:US
Mailing Address - Phone:307-632-0728
Mailing Address - Fax:
Practice Address - Street 1:1331 PRAIRIE AVE STE 1
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-4867
Practice Address - Country:US
Practice Address - Phone:307-632-0728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-23
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036091285207Q00000X
WY5108A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036091285Medicaid
IL553180OtherMEDICARE GROUP PTAN
IL834340OtherMEDICAR GROUP PTAN
IL834340016Medicare PIN
IL834340OtherMEDICAR GROUP PTAN
ILF30432Medicare UPIN
ILL71913Medicare PIN