Provider Demographics
NPI:1356003867
Name:DOUGLAS, SAMUEL (PT, DPT)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 VERNON ST APT 203
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94610-1402
Mailing Address - Country:US
Mailing Address - Phone:510-292-8669
Mailing Address - Fax:
Practice Address - Street 1:3300 WEBSTER ST STE 703
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3122
Practice Address - Country:US
Practice Address - Phone:510-835-5633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-12
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA300980208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation