Basic Information
| Provider Information | |||||||||
| NPI: | 1679679484 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NATHANSON | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | C. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 100 N ACADEMY AVE | ||||||||
| Address2: | CREDENTIALS DEPT | ||||||||
| City: | DANVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178224903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5702716144 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1000 E MOUNTAIN BLVD | ||||||||
| Address2: | |||||||||
| City: | WILKES BARRE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 187110027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708086026 | ||||||||
| FaxNumber: | 5708087943 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2006 | ||||||||
| LastUpdateDate: | 08/24/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | MD049454L | PA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 0014441460007 | 05 | PA | MEDICAID |