Basic Information
| Provider Information | |||||||||
| NPI: | 1053416313 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOUGLAS | ||||||||
| FirstName: | DONALD | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 733 CHINKAPIN DRIVE | ||||||||
| Address2: | STE 2 | ||||||||
| City: | NICHOLASVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592230721 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2537 LARKIN RD | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405033201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2705545114 | ||||||||
| FaxNumber: | 2702154834 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2006 | ||||||||
| LastUpdateDate: | 06/09/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | 26259 | KY | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 208100000X | 26259 | KY | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 164291501 | 01 | U. S. DOL | OTHER | 000000108104 | 01 | KY | ANTHEM PIN | OTHER | 64262595 | 05 | KY | MEDICAID | F14766 | 01 | KY | BLUEGRASS FAMILY HEALTH | OTHER | 611369666 | 01 | KY | HUMANA PIN | OTHER | 2000319 | 01 | KY | UNITED HEALTHCARE | OTHER |