Provider Demographics
NPI:1922494889
Name:LATER, DOUGLAS JAMES (DO)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:JAMES
Last Name:LATER
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 1:1055 N 300 W STE 311
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3373
Mailing Address - Country:US
Mailing Address - Phone:801-357-7883
Mailing Address - Fax:801-357-7975
Practice Address - Street 1:1055 N 300 W STE 311
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3373
Practice Address - Country:US
Practice Address - Phone:801-357-7883
Practice Address - Fax:801-357-7975
Is Sole Proprietor?:No
Enumeration Date:2015-04-07
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT10663165-1204208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program