Provider Demographics
NPI:1477761914
Name:DOUGLAS W ANKROM, MD, INC
Entity Type:Organization
Organization Name:DOUGLAS W ANKROM, MD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:WARREN
Authorized Official - Last Name:ANKROM
Authorized Official - Suffix:
Authorized Official - Credentials:MD,
Authorized Official - Phone:209-533-3321
Mailing Address - Street 1:680 GUZZI LN STE 205
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-5288
Mailing Address - Country:US
Mailing Address - Phone:209-533-3321
Mailing Address - Fax:209-533-3118
Practice Address - Street 1:680 GUZZI LN STE 205
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-5288
Practice Address - Country:US
Practice Address - Phone:209-533-3321
Practice Address - Fax:209-533-3118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52517174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ02112ZMedicare PIN