Provider Demographics
NPI:1437831781
Name:DOUGLASS, PHILLIP L
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:L
Last Name:DOUGLASS
Suffix:
Gender:M
Credentials:
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 200239
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:CO
Mailing Address - Zip Code:80620-0239
Mailing Address - Country:US
Mailing Address - Phone:720-546-1668
Mailing Address - Fax:
Practice Address - Street 1:1140 M ST
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631-9586
Practice Address - Country:US
Practice Address - Phone:970-313-1173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker