Provider Demographics
NPI:1477793727
Name:DOUGLAS, WILLIAM GLEN (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:GLEN
Last Name:DOUGLAS
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 1:1860 HOWE AVE STE 440
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-1098
Mailing Address - Country:US
Mailing Address - Phone:916-569-8484
Mailing Address - Fax:
Practice Address - Street 1:3701 J ST STE 201
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5542
Practice Address - Country:US
Practice Address - Phone:916-454-2345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-26
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG46175208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice