Provider Demographics
NPI:1477041010
Name:DOUGLAS, GARY RALPH (DC)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:RALPH
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3077 E COMMERCIAL BLVD # 1A
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-4311
Mailing Address - Country:US
Mailing Address - Phone:954-626-6446
Mailing Address - Fax:
Practice Address - Street 1:3077 E COMMERCIAL BLVD # 1A
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-4311
Practice Address - Country:US
Practice Address - Phone:954-626-6446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-30
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH3492111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor