Provider Demographics
NPI:1659318194
Name:DOUGLAS, SCOTT K (MD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:K
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:413 E JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:CRAWFORDSVLLE
Mailing Address - State:IN
Mailing Address - Zip Code:47933-2929
Mailing Address - Country:US
Mailing Address - Phone:765-366-2787
Mailing Address - Fax:765-366-2787
Practice Address - Street 1:1640 CRAWFORDSVILLE SQUARE DR
Practice Address - Street 2:
Practice Address - City:CRAWFORDSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47933-3800
Practice Address - Country:US
Practice Address - Phone:765-362-5789
Practice Address - Fax:765-362-2453
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01037795207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100466830Medicaid
INM471400008OtherMEDICARE PROVIDER PTAN
E17121Medicare UPIN
IN100466830Medicaid