Provider Demographics
NPI:1477534998
Name:PHILLIPS, DOUGLAS LEON II (DO)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:LEON
Last Name:PHILLIPS
Suffix:II
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1234 E DUPONT RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1545
Mailing Address - Country:US
Mailing Address - Phone:260-373-9700
Mailing Address - Fax:260-458-5664
Practice Address - Street 1:8607 TEMPLE DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46809-3048
Practice Address - Country:US
Practice Address - Phone:260-478-9220
Practice Address - Fax:260-478-9172
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001562207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100362730Medicaid
IN224620CMedicare PIN
INF63227Medicare UPIN