Provider Demographics
NPI:1780352054
Name:DOUGLASS, KRISTEN MARIE (MD)
Entity type:Individual
Prefix:DR
First Name:KRISTEN
Middle Name:MARIE
Last Name:DOUGLASS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23878 SW ROBSON TER
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:OR
Mailing Address - Zip Code:97140-7057
Mailing Address - Country:US
Mailing Address - Phone:503-523-9344
Mailing Address - Fax:
Practice Address - Street 1:8645 SE SUNNYBROOK BLVD STE UNIT200
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-6841
Practice Address - Country:US
Practice Address - Phone:503-659-1694
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-01
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD203546208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty