Provider Demographics
NPI:1972530335
Name:DOUGLAS, JOHN WILLIAM (MD)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:WILLIAM
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 1810
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39502
Mailing Address - Country:US
Mailing Address - Phone:228-575-1194
Mailing Address - Fax:228-575-2917
Practice Address - Street 1:15190 COMMUNITY RD
Practice Address - Street 2:SUITE 220
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3485
Practice Address - Country:US
Practice Address - Phone:228-539-3356
Practice Address - Fax:228-539-3225
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS08130174400000X
MS8130207RP1001X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No174400000XOther Service ProvidersSpecialist
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00019714Medicaid
MS08130OtherSTATE LICENSE
MS00019714Medicaid
MS08130OtherSTATE LICENSE