Provider Demographics
NPI:1740066018
Name:ROBINSON, DOUGLAS MACK JR
Entity type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:MACK
Last Name:ROBINSON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4813 RIDGE RD # 113-624
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-6117
Mailing Address - Country:US
Mailing Address - Phone:888-518-3113
Mailing Address - Fax:
Practice Address - Street 1:4813 RIDGE RD # 113-624
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-6117
Practice Address - Country:US
Practice Address - Phone:888-518-3113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-04
Last Update Date:2023-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA060204330172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver