Provider Demographics
NPI:1508835737
Name:DOUGLAS, LEONARD WALTER JR (MD)
Entity Type:Individual
Prefix:DR
First Name:LEONARD
Middle Name:WALTER
Last Name:DOUGLAS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:9237 UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:N CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9189
Mailing Address - Country:US
Mailing Address - Phone:843-577-5011
Mailing Address - Fax:843-863-0398
Practice Address - Street 1:9237 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:N CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9189
Practice Address - Country:US
Practice Address - Phone:843-577-5011
Practice Address - Fax:843-863-0398
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11395207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAA50754950OtherMEDICARE PTAN
SC113950Medicaid
SCB920294950Medicare PIN
B92029Medicare UPIN