Provider Demographics
NPI:1235174830
Name:RE, DOUGLAS (PA)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:
Last Name:RE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:861 SW 78TH AVE
Mailing Address - Street 2:SUITE #100B
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-3229
Mailing Address - Country:US
Mailing Address - Phone:954-693-0000
Mailing Address - Fax:954-693-0005
Practice Address - Street 1:6001 WEBB RD
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33615-3241
Practice Address - Country:US
Practice Address - Phone:813-888-7060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-18
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103254363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL292115400Medicaid
FLQ44344Medicare UPIN