Provider Demographics
NPI:1497700355
Name:HARGRAVE, DOUGLAS M (DO)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:M
Last Name:HARGRAVE
Suffix:
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:PO BOX 310
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08350-0310
Mailing Address - Country:US
Mailing Address - Phone:856-697-0300
Mailing Address - Fax:856-697-8944
Practice Address - Street 1:1315 HARDING HWY
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:NJ
Practice Address - Zip Code:08350-2205
Practice Address - Country:US
Practice Address - Phone:856-697-0300
Practice Address - Fax:856-697-8944
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB64919207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1497700355OtherMEDICARE NPI
NJ7733305Medicaid
NJ1497700355OtherMEDICARE NPI
NJG74722Medicare UPIN