Provider Demographics
NPI:1205856473
Name:DOUX, JOHN DWIGHT (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DWIGHT
Last Name:DOUX
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 1:434 TRAVERSO AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-1134
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:151 CALLAN AVE STE 101
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-4536
Practice Address - Country:US
Practice Address - Phone:510-686-3894
Practice Address - Fax:206-350-4752
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2011-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA061847207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG90023Medicare UPIN