Provider Demographics
NPI:1558390393
Name:ANKROM, DOUGLAS (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:ANKROM
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 1:680 GUZZI LN STE 205
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-5288
Mailing Address - Country:US
Mailing Address - Phone:209-533-3321
Mailing Address - Fax:209-533-3118
Practice Address - Street 1:680 GUZZI LN STE 205
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-5288
Practice Address - Country:US
Practice Address - Phone:209-533-3321
Practice Address - Fax:209-533-3118
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-02
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52517208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A525170Medicare PIN