Provider Demographics
NPI:1104856475
Name:CUNNINGHAM, DOUGLAS L (DO)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:L
Last Name:CUNNINGHAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4350 N 19TH AVE
Mailing Address - Street 2:SUITE 6
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-4602
Mailing Address - Country:US
Mailing Address - Phone:602-264-9191
Mailing Address - Fax:602-532-2973
Practice Address - Street 1:4350 N 19TH AVE
Practice Address - Street 2:SUITE 6
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-4602
Practice Address - Country:US
Practice Address - Phone:602-264-9191
Practice Address - Fax:602-532-2973
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2325207QG0300X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ2246760-01Medicaid
AZ2246760-01Medicaid
C98198Medicare UPIN