Provider Demographics
NPI:1497733893
Name:DOUGLAS, STEVEN L (MD)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:L
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:PO BOX 801143
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-1143
Mailing Address - Country:US
Mailing Address - Phone:573-331-5583
Mailing Address - Fax:573-331-5079
Practice Address - Street 1:320 N LINCOLN ST
Practice Address - Street 2:
Practice Address - City:EAST PRAIRIE
Practice Address - State:MO
Practice Address - Zip Code:63845-1160
Practice Address - Country:US
Practice Address - Phone:573-649-3026
Practice Address - Fax:573-649-5600
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMD114557207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO209992403Medicaid
MO43074141063801A003OtherTRICARE NUMBER
MO430741410OtherFIRST HEALTH NUMBER
MO383074OtherHEALTHLINK NUMBER
MO116266OtherMO NUMBER
MO43074141063801A003OtherTRICARE NUMBER
MO209992403Medicaid