Provider Demographics
NPI:1710926860
Name:DOUGLAS, DAVID WAYMON (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:WAYMON
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 1:423 CEDAR RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40744-7446
Mailing Address - Country:US
Mailing Address - Phone:606-878-9020
Mailing Address - Fax:
Practice Address - Street 1:1 TRILLIUM WAY
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-8426
Practice Address - Country:US
Practice Address - Phone:606-528-1212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-05
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY25732207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64338304Medicaid
KY000000074020OtherBLUE CROSS BLUE SHIELD
KY0954326Medicare ID - Type Unspecified
KY64338304Medicaid