Provider Demographics
NPI:1376598938
Name:DOCTOR, DOUGLAS DEAN (MD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:DEAN
Last Name:DOCTOR
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 1:707 E CEDAR ST
Mailing Address - Street 2:STE 200
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-4207
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17321 STATE ROAD 23
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1531
Practice Address - Country:US
Practice Address - Phone:574-335-8400
Practice Address - Fax:574-335-0796
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036380207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000215746OtherBCBS
IN000000579960OtherBCBS
IN100205190AMedicaid
IN000000579960OtherBCBS
IND94681Medicare UPIN
IN187580EMedicare PIN
IN000000215746OtherBCBS
ININ1133007Medicare PIN