Provider Demographics
NPI:1679986277
Name:DOUGLAS, STEPHANIE (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4455 DUNCAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1111
Mailing Address - Country:US
Mailing Address - Phone:617-419-0613
Mailing Address - Fax:
Practice Address - Street 1:4455 DUNCAN AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1111
Practice Address - Country:US
Practice Address - Phone:617-419-0613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-11
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAETL-6027208D00000X
IN01084127A208D00000X
MO2021025372208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice