Provider Demographics
NPI:1225228034
Name:FIFE, DOUGLAS JACKSON (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:JACKSON
Last Name:FIFE
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 1:6460 MEDICAL CENTER ST
Mailing Address - Street 2:SUITE 350
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148
Mailing Address - Country:US
Mailing Address - Phone:702-255-6647
Mailing Address - Fax:702-933-1444
Practice Address - Street 1:6460 MEDICAL CENTER ST
Practice Address - Street 2:SUITE 350
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148
Practice Address - Country:US
Practice Address - Phone:702-255-6647
Practice Address - Fax:702-933-1444
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-27
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA95522174400000X
NV13164174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist