Provider Demographics
NPI:1467452813
Name:DOUGLAS, EDWARD R (DO)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:R
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:3829 S JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-5376
Mailing Address - Country:US
Mailing Address - Phone:417-890-5585
Mailing Address - Fax:417-877-0970
Practice Address - Street 1:3829 S JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5376
Practice Address - Country:US
Practice Address - Phone:417-890-5585
Practice Address - Fax:417-877-0970
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2011-04-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2002013903204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
I09016Medicare UPIN