Provider Demographics
NPI:1851391908
Name:DOUGLAS, JOHN ANTONI (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ANTONI
Last Name:DOUGLAS
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 1:2321 N 400 E STE 300
Mailing Address - Street 2:
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074-3440
Mailing Address - Country:US
Mailing Address - Phone:435-833-9180
Mailing Address - Fax:435-883-9177
Practice Address - Street 1:2321 N 400 E STE 300
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-3440
Practice Address - Country:US
Practice Address - Phone:435-833-9180
Practice Address - Fax:435-883-9177
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-29
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT56170741204207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
H01502Medicare UPIN
UT005777101Medicare PIN