Provider Demographics
NPI:1790869659
Name:MAIN, DOUGLAS (DC)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:
Last Name:MAIN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 TIMBER TRL
Mailing Address - Street 2:
Mailing Address - City:BOONTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07005-9553
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:342 PARSIPPANY RD
Practice Address - Street 2:
Practice Address - City:PARSIPPANY
Practice Address - State:NJ
Practice Address - Zip Code:07054-1275
Practice Address - Country:US
Practice Address - Phone:973-428-8264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00205300111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor