Provider Demographics
NPI:1750096525
Name:DOUGLAS, JULIAN DANTE'
Entity type:Individual
Prefix:
First Name:JULIAN
Middle Name:DANTE'
Last Name:DOUGLAS
Suffix:
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 1:6231 OLD MILL RD APT 110
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-5125
Mailing Address - Country:US
Mailing Address - Phone:434-338-9730
Mailing Address - Fax:
Practice Address - Street 1:6231 OLD MILL RD APT 110
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-5125
Practice Address - Country:US
Practice Address - Phone:434-338-9730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-17
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer