Basic Information
| Provider Information | |||||||||
| NPI: | 1417931528 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EGLEN | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6908 | ||||||||
| Address2: | |||||||||
| City: | KOKOMO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469046908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148218055 | ||||||||
| FaxNumber: | 3148211833 | ||||||||
| Practice Location | |||||||||
| Address1: | 1907 W SYCAMORE ST | ||||||||
| Address2: | |||||||||
| City: | KOKOMO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469014113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654565729 | ||||||||
| FaxNumber: | 7654565014 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 01024933A | IN | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 000000101429 | 01 | IN | INDIANA COMPREHENSIVE | OTHER | 344280 | 01 | HEALTHLINK | OTHER |