Provider Demographics
NPI:1417931528
Name:EGLEN, DOUGLAS E (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:E
Last Name:EGLEN
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:PO BOX 6908
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46904-6908
Mailing Address - Country:US
Mailing Address - Phone:314-821-8055
Mailing Address - Fax:314-821-1833
Practice Address - Street 1:1907 W SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46901-4113
Practice Address - Country:US
Practice Address - Phone:765-456-5729
Practice Address - Fax:765-456-5014
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01024933A207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000101429OtherINDIANA COMPREHENSIVE
344280OtherHEALTHLINK
INE83515Medicare UPIN
344280OtherHEALTHLINK