Provider Demographics
NPI:1922040955
Name:DOUGLAS, FREDERICK G (MD)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:G
Last Name:DOUGLAS
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:PO BOX 2089
Mailing Address - Street 2:
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29641-2089
Mailing Address - Country:US
Mailing Address - Phone:864-855-5104
Mailing Address - Fax:864-859-9362
Practice Address - Street 1:106 JOHN STREET
Practice Address - Street 2:
Practice Address - City:EASLEY
Practice Address - State:SC
Practice Address - Zip Code:29640-1415
Practice Address - Country:US
Practice Address - Phone:864-859-2220
Practice Address - Fax:864-859-5744
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5691207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC582296052055OtherBLUE CROSS
SC134768Medicaid
SC056913Medicaid
SC582296052055OtherBLUE CROSS
SC134768Medicaid
SCD908159367Medicare PIN