Provider Demographics
NPI:1922096668
Name:DOUGLAS, GARY (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
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 1:1026 UNION RD
Mailing Address - Street 2:
Mailing Address - City:WEST SENECA
Mailing Address - State:NY
Mailing Address - Zip Code:14224-3449
Mailing Address - Country:US
Mailing Address - Phone:716-712-0858
Mailing Address - Fax:716-712-0859
Practice Address - Street 1:1026 UNION RD
Practice Address - Street 2:
Practice Address - City:WEST SENECA
Practice Address - State:NY
Practice Address - Zip Code:14224-3449
Practice Address - Country:US
Practice Address - Phone:716-712-0858
Practice Address - Fax:716-712-0859
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY198135208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000523560007OtherBC/BS
NY040426002829OtherFIDELIS
NY148117FLOtherPREFERRED CARE
NY00010047904OtherUNIVERA
NY01545188Medicaid
NY1709798OtherIHA
NY1709798OtherIHA
DD4136Medicare ID - Type Unspecified