Provider Demographics
NPI:1639122831
Name:DOUGLAS, ANTHONY E (MD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:E
Last Name:DOUGLAS
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 1:670 N ORLANDO AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-4481
Mailing Address - Country:US
Mailing Address - Phone:407-644-7551
Mailing Address - Fax:407-644-7121
Practice Address - Street 1:670 N ORLANDO AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-4481
Practice Address - Country:US
Practice Address - Phone:407-644-7551
Practice Address - Fax:407-644-7121
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2007-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME84368207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00044141OtherRAILROAD MEDICARE
FL13399OtherBCBS
H60479Medicare UPIN
FL13399OtherBCBS