Provider Demographics
NPI:1578849360
Name:JAY PAUL DOUGLASS MD LLC
Entity Type:Organization
Organization Name:JAY PAUL DOUGLASS MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JAY PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUGLASS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-635-6256
Mailing Address - Street 1:16463 BOONES FERRY RD STE 300
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-4376
Mailing Address - Country:US
Mailing Address - Phone:503-635-6256
Mailing Address - Fax:503-636-9604
Practice Address - Street 1:16463 BOONES FERRY RD STE 300
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-4376
Practice Address - Country:US
Practice Address - Phone:503-635-6256
Practice Address - Fax:503-636-9604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-25
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD153785207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty