Provider Demographics
NPI:1780677906
Name:CALVIN, DOUGLAS P (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:P
Last Name:CALVIN
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 1:3232 N BALLARD RD STE 200
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-8804
Mailing Address - Country:US
Mailing Address - Phone:920-749-9668
Mailing Address - Fax:920-734-5307
Practice Address - Street 1:3925 N GATEWAY DR
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-7863
Practice Address - Country:US
Practice Address - Phone:920-749-1171
Practice Address - Fax:920-749-1172
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13714207R00000X, 2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL005570200Medicaid
FL005570200Medicaid
FL35728RMedicare PIN