Provider Demographics
NPI:1780661314
Name:MAGUIRE, DOUGLAS L (DPM)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:L
Last Name:MAGUIRE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-7724
Mailing Address - Country:US
Mailing Address - Phone:616-392-7472
Mailing Address - Fax:
Practice Address - Street 1:904 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-7724
Practice Address - Country:US
Practice Address - Phone:616-392-7472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-24
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIDM001062213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2637281Medicaid
MIMO10933OtherCHAMPUS
MI4242631OtherAETNA
MI0M15760Medicare ID - Type Unspecified
MI0406640001Medicare NSC
MI4242631OtherAETNA