Provider Demographics
NPI:1942314620
Name:TICE, DOUGLAS SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:SCOTT
Last Name:TICE
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 1:309 MEDICAL CT
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25401-2843
Mailing Address - Country:US
Mailing Address - Phone:304-263-0953
Mailing Address - Fax:304-263-5826
Practice Address - Street 1:309 MEDICAL CT
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-2843
Practice Address - Country:US
Practice Address - Phone:304-263-0953
Practice Address - Fax:304-263-5826
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD53001207X00000X, 207XX0801X
WV16852207X00000X, 207XX0801X
PAMD066898L207X00000X
NC200400986207X00000X, 207XX0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
F48902Medicare UPIN