Provider Demographics
NPI:1700856911
Name:GRIFFIN, DOUGLAS M (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:M
Last Name:GRIFFIN
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 1:736 BROADWAY N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-4421
Mailing Address - Country:US
Mailing Address - Phone:701-234-6160
Mailing Address - Fax:
Practice Address - Street 1:736 BROADWAY N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-4421
Practice Address - Country:US
Practice Address - Phone:701-234-6160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2018-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN31087207Q00000X
ND13899207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN595969OtherAMERICA'S PPO
MNA013OtherCHAMPUS
MN0103802OtherMEDICA
MN451595100Medicaid
MN114455D277OtherUCARE
MN01011082OtherPREFERRED ONE
MNHP21657OtherHEALTH PARTNERS
MN53Q29GROtherBLUE SHIELD
MNA013OtherCHAMPUS
MN451595100Medicaid