Provider Demographics
NPI:1346456399
Name:DOUGLAS, GEOFFREY (MD)
Entity Type:Individual
Prefix:DR
First Name:GEOFFREY
Middle Name:
Last Name:DOUGLAS
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 1:3016 W CHARLESTON BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-1973
Mailing Address - Country:US
Mailing Address - Phone:702-218-0915
Mailing Address - Fax:
Practice Address - Street 1:1707 W CHARLESTON BLVD STE 160
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-2354
Practice Address - Country:US
Practice Address - Phone:701-671-5150
Practice Address - Fax:702-384-6493
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD.32676208600000X
WI634602086S0102X, 208600000X
NV165322086S0102X
FLME1278552086S0127X
CAA101528208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL113025700Medicaid