Provider Demographics
NPI:1497733109
Name:DOUGLAS, STEPHEN KIRK (NP)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:KIRK
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1481 W 10TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-2803
Mailing Address - Country:US
Mailing Address - Phone:317-988-2972
Mailing Address - Fax:
Practice Address - Street 1:2675 FOXPOINTE DRIVE
Practice Address - Street 2:SUITE B
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47203
Practice Address - Country:US
Practice Address - Phone:812-375-0000
Practice Address - Fax:812-375-0711
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001649A363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000321795OtherBLUE CROSS BLUE SHIELD
INQ14289Medicare UPIN
IN000000321795OtherBLUE CROSS BLUE SHIELD