Provider Demographics
NPI:1679614861
Name:DOUGAN, MAX R JR (MD)
Entity Type:Individual
Prefix:
First Name:MAX
Middle Name:R
Last Name:DOUGAN
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 1:154 PERKINS EXTD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38117
Mailing Address - Country:US
Mailing Address - Phone:901-767-4353
Mailing Address - Fax:
Practice Address - Street 1:3000 GETWELL RD
Practice Address - Street 2:DELTA MEDICAL CENTER
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38118-2205
Practice Address - Country:US
Practice Address - Phone:901-369-8560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE39942085R0202X
TNMD0135062085R0202X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3006364Medicaid
3006365Medicare ID - Type Unspecified
TN3006364Medicaid