Provider Demographics
NPI:1609865302
Name:TOLER, DOUGLAS GLEN (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:GLEN
Last Name:TOLER
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 1:8 CHURCHILL DOWNS
Mailing Address - Street 2:
Mailing Address - City:DUNCANVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75116-2046
Mailing Address - Country:US
Mailing Address - Phone:972-966-7828
Mailing Address - Fax:972-332-4217
Practice Address - Street 1:1305 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75165-2269
Practice Address - Country:US
Practice Address - Phone:972-966-7867
Practice Address - Fax:972-332-4217
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG1564207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX17965702Medicaid
TX17965702Medicaid
TX17965702Medicaid