Provider Demographics
NPI:1982643482
Name:DOUGLAS, KELVIN L (MD)
Entity Type:Individual
Prefix:
First Name:KELVIN
Middle Name:L
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 1:1505 WOODLAWN AVE
Mailing Address - Street 2:STE A
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024
Mailing Address - Country:US
Mailing Address - Phone:731-287-1500
Mailing Address - Fax:731-285-5200
Practice Address - Street 1:2156-B N. HIGHLAND AVE
Practice Address - Street 2:STE 282
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305
Practice Address - Country:US
Practice Address - Phone:731-499-2791
Practice Address - Fax:731-285-5200
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN26349207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN17154Medicaid
TN4106545Medicaid
TN4106545OtherBCBST
TN3090776Medicaid
TN171276Medicaid
TN35464Medicaid
TN3090776Medicaid