Provider Demographics
NPI:1346200656
Name:DOUGLASS, WILLIAM P (MD)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:P
Last Name:DOUGLASS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:569 HEALTH BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-1499
Mailing Address - Country:US
Mailing Address - Phone:386-258-7668
Mailing Address - Fax:386-258-7671
Practice Address - Street 1:303 N CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114
Practice Address - Country:US
Practice Address - Phone:386-254-4139
Practice Address - Fax:386-258-8265
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0015015207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
716302Medicare ID - Type Unspecified
D58137Medicare UPIN