Provider Demographics
NPI:1770700080
Name:DOUGLAS, MATTHEW L (MD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:L
Last Name:DOUGLAS
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 1:10350 E DAKOTA AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80247-1314
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1375 E 19TH AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80218-1114
Practice Address - Country:US
Practice Address - Phone:303-338-4545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO40452207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
014434OtherKAISER-COMMERCIAL NUMBER
CO62101366Medicaid
CO62101366Medicaid
014434OtherKAISER-COMMERCIAL NUMBER