Provider Demographics
NPI:1790785954
Name:DOUGLAS, JAMES TODD (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:TODD
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:J
Other - Middle Name:TODD
Other - Last Name:DOUGLAS MD PSC
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:3 MARYLAND FARMS
Mailing Address - Street 2:SUITE 250
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5005
Mailing Address - Country:US
Mailing Address - Phone:615-372-5516
Mailing Address - Fax:866-638-0971
Practice Address - Street 1:1325 ANDREA ST
Practice Address - Street 2:SUITE 100
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-5852
Practice Address - Country:US
Practice Address - Phone:270-901-3454
Practice Address - Fax:270-901-3459
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY34188207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYG28780Medicare UPIN
KY65903239Medicaid
KY1721501Medicare PIN
KY64341886Medicaid