Provider Demographics
NPI:1558308270
Name:ANTHONY, DOUGLAS C (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:C
Last Name:ANTHONY
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 1:593 EDDY ST
Mailing Address - Street 2:APC BUILDING, 12-106
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4923
Mailing Address - Country:US
Mailing Address - Phone:401-444-5011
Mailing Address - Fax:
Practice Address - Street 1:593 EDDY ST
Practice Address - Street 2:APC BUILDING, 12-106
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4923
Practice Address - Country:US
Practice Address - Phone:401-444-5011
Practice Address - Fax:401-444-8514
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002000486207ZP0102X, 207ZN0500X, 207ZP0101X
RIMD13805207ZP0102X, 207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZN0500XAllopathic & Osteopathic PhysiciansPathologyNeuropathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO127403OtherBLUE CHOICE
RI002577701OtherMEDICARE
MO127403OtherBLUE SHIELD
MO205733702Medicaid
MOP00601089Medicare PIN
RI002577701OtherMEDICARE
MO220033230Medicare PIN
MO966995236Medicare PIN
MO127403OtherBLUE CHOICE