Provider Demographics
NPI:1750499893
Name:CONGDON, DOUGLAS DAVID (DO)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:DAVID
Last Name:CONGDON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 33321
Mailing Address - Street 2:DRAWER 129
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48232-5321
Mailing Address - Country:US
Mailing Address - Phone:800-288-8325
Mailing Address - Fax:419-866-5453
Practice Address - Street 1:1 HURLEY PLZ
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-5902
Practice Address - Country:US
Practice Address - Phone:810-262-9134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101009572207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1001298OtherMCLAREN HEALTH ADVANTAGE
MI2747668OtherHEALTH PLAN OF MI
MI4553OtherCOMMUNITY CHOICE OF MI
MI1001298OtherMCLAREN HEALTH PLAN
MI2747668Medicaid
MI220007715OtherRAILROAD MEDICARE
MI2747668OtherHEALTH PLAN OF MI
MI2747668Medicaid