Provider Demographics
NPI:1518163252
Name:MARK L. DOUGLAS, DO
Entity Type:Organization
Organization Name:MARK L. DOUGLAS, DO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HILDA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAXWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-776-5594
Mailing Address - Street 1:130 GOFF MOUNTAIN RD
Mailing Address - Street 2:STE 12
Mailing Address - City:CROSS LANES
Mailing Address - State:WV
Mailing Address - Zip Code:25313-1419
Mailing Address - Country:US
Mailing Address - Phone:304-776-5594
Mailing Address - Fax:304-776-3521
Practice Address - Street 1:130 GOFF MOUNTAIN RD
Practice Address - Street 2:STE 12
Practice Address - City:CROSS LANES
Practice Address - State:WV
Practice Address - Zip Code:25313-1419
Practice Address - Country:US
Practice Address - Phone:304-776-5594
Practice Address - Fax:304-776-3521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9311501Medicare ID - Type UnspecifiedGROUP NUMBER