Provider Demographics
NPI:1477564342
Name:DOUGLASS, CARY DALE (MD)
Entity Type:Individual
Prefix:
First Name:CARY
Middle Name:DALE
Last Name:DOUGLASS
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 1:6109 GINITA LN
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78739-1639
Mailing Address - Country:US
Mailing Address - Phone:512-961-6761
Mailing Address - Fax:888-687-2607
Practice Address - Street 1:6109 GINITA LN
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78739-1639
Practice Address - Country:US
Practice Address - Phone:512-961-6761
Practice Address - Fax:888-687-2607
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3085207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXJ3085OtherLICENSE NUMBER
TXF30152Medicare UPIN