Provider Demographics
NPI:1568499226
Name:NORMAN, DOUGLAS P (MD)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:P
Last Name:NORMAN
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 1:755 HOSPITAL WAY
Mailing Address - Street 2:SUITE A4
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-2717
Mailing Address - Country:US
Mailing Address - Phone:208-233-8770
Mailing Address - Fax:208-233-2946
Practice Address - Street 1:755 HOSPITAL WAY
Practice Address - Street 2:SUITE A4
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2717
Practice Address - Country:US
Practice Address - Phone:208-233-8770
Practice Address - Fax:208-233-2946
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM3407174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1110533Medicare ID - Type Unspecified
IDC36836Medicare UPIN