Basic Information
| Provider Information | |||||||||
| NPI: | 1316175797 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOUGLAS | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | ALLEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3805 CHEROKEE ST NW | ||||||||
| Address2: | |||||||||
| City: | KENNESAW | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301442085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704265666 | ||||||||
| FaxNumber: | 7704201794 | ||||||||
| Practice Location | |||||||||
| Address1: | 3805 CHEROKEE ST NW | ||||||||
| Address2: | |||||||||
| City: | KENNESAW | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301442085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704265666 | ||||||||
| FaxNumber: | 7704201794 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2009 | ||||||||
| LastUpdateDate: | 02/11/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | D74188 | MD | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 72824 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.