Provider Demographics
NPI:1952396103
Name:DOUGLASS, TAMARA SMITH (MD)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:SMITH
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 1:1009 MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:FORTUNA
Mailing Address - State:CA
Mailing Address - Zip Code:95540-2811
Mailing Address - Country:US
Mailing Address - Phone:707-845-5153
Mailing Address - Fax:
Practice Address - Street 1:638 MAIN STREET
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:CA
Practice Address - Zip Code:95536-1157
Practice Address - Country:US
Practice Address - Phone:707-786-4028
Practice Address - Fax:707-786-9029
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2023-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA92702207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1952396103OtherNATIONAL PROVIDER IDENTIFICATION
CA156653Medicare UPIN