Provider Demographics
NPI:1629037437
Name:HOLSCLAW, DOUGLAS STANLEY JR (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:STANLEY
Last Name:HOLSCLAW
Suffix:JR
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 1:42 LLANBERRIS RD
Mailing Address - Street 2:
Mailing Address - City:BALA CYNWYD
Mailing Address - State:PA
Mailing Address - Zip Code:19004-2403
Mailing Address - Country:US
Mailing Address - Phone:610-664-3712
Mailing Address - Fax:
Practice Address - Street 1:42 LLANBERRIS RD
Practice Address - Street 2:
Practice Address - City:BALA CYNWYD
Practice Address - State:PA
Practice Address - Zip Code:19004-2403
Practice Address - Country:US
Practice Address - Phone:610-664-3712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-21
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD012316E207RP1001X, 2080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric Pulmonology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA099759OtherBLUE SHIELD
PA0006732510013Medicaid
PA0006732510013Medicaid