Provider Demographics
NPI:1649254004
Name:PHILLIPS, DOUGLAS R (MD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:R
Last Name:PHILLIPS
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 1:2428 MERRICK RD
Mailing Address - Street 2:
Mailing Address - City:BELLMORE
Mailing Address - State:NY
Mailing Address - Zip Code:11710
Mailing Address - Country:US
Mailing Address - Phone:516-379-2689
Mailing Address - Fax:516-992-8380
Practice Address - Street 1:2428 MERRICK RD
Practice Address - Street 2:
Practice Address - City:BELLMORE
Practice Address - State:NY
Practice Address - Zip Code:11710
Practice Address - Country:US
Practice Address - Phone:516-379-2689
Practice Address - Fax:516-992-8380
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY130753207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
C06796Medicare UPIN
NY577D4XYPW1Medicare PIN
71F291Medicare ID - Type Unspecified