Provider Demographics
NPI:1093721938
Name:BISHOP, DOUGLAS S (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:S
Last Name:BISHOP
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 GOLDEN CENTER DR
Mailing Address - Street 2:STE A
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667-6278
Mailing Address - Country:US
Mailing Address - Phone:530-344-2020
Mailing Address - Fax:530-622-9613
Practice Address - Street 1:4300 GOLDEN CENTER DR
Practice Address - Street 2:STE A
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-6278
Practice Address - Country:US
Practice Address - Phone:530-344-2020
Practice Address - Fax:530-622-9613
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG52918207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0065830Medicaid
CAG52918OtherSTATE LICENSE
CAZZZ00637ZMedicare ID - Type UnspecifiedMEDICARE GROUP ID
CAC36123Medicare UPIN