Provider Demographics
NPI:1164413944
Name:POWELL, DOUGLASS (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLASS
Middle Name:
Last Name:POWELL
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 1:792 N MAIN ST
Mailing Address - Street 2:SUITE 100A
Mailing Address - City:NORTH SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13212-1644
Mailing Address - Country:US
Mailing Address - Phone:315-423-9722
Mailing Address - Fax:315-423-9687
Practice Address - Street 1:4820 W TAFT RD
Practice Address - Street 2:SUITE 208
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-2800
Practice Address - Country:US
Practice Address - Phone:315-451-2261
Practice Address - Fax:315-451-3162
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY140371207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB82615Medicare UPIN
NYBB9700Medicare ID - Type Unspecified