Provider Demographics
NPI:1023099736
Name:DOUGLASS, ANDREW MARTIN (MD)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:MARTIN
Last Name:DOUGLASS
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 52333
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37950-2333
Mailing Address - Country:US
Mailing Address - Phone:865-686-0507
Mailing Address - Fax:865-357-8346
Practice Address - Street 1:1344 DOWELL SPRINGS BLVD
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37909-2453
Practice Address - Country:US
Practice Address - Phone:865-686-0507
Practice Address - Fax:865-357-8346
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-09
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN021979174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP00171113OtherMEDICARE RAILROAD
TN3093765Medicare ID - Type Unspecified
TNF35580Medicare UPIN