Provider Demographics
NPI:1497299036
Name:DOUGLAS, DONOVAN
Entity Type:Individual
Prefix:
First Name:DONOVAN
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25111 GRODAN DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-2529
Mailing Address - Country:US
Mailing Address - Phone:313-510-5230
Mailing Address - Fax:
Practice Address - Street 1:25111 GRODAN DR
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48033-2529
Practice Address - Country:US
Practice Address - Phone:313-510-5230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-16
Last Update Date:2016-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other