Provider Demographics
NPI:1841371853
Name:DOUGLAS, ELAINE (MD)
Entity type:Individual
Prefix:DR
First Name:ELAINE
Middle Name:
Last Name:DOUGLAS
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 1:160 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-4432
Mailing Address - Country:US
Mailing Address - Phone:973-744-0528
Mailing Address - Fax:
Practice Address - Street 1:160 LINCOLN STREET
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-4432
Practice Address - Country:US
Practice Address - Phone:973-744-0528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05226500207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJOK1590OtherHEALTHNET
NJ25MA05226500OtherLICENSE
NJP375146OtherOXFORD
NJ31D0896592OtherCLIA
NJD04980000OtherCDS
NJD04980000OtherCDS
NJ31D0896592OtherCLIA
E27332Medicare UPIN