Basic Information
Provider Information | |||||||||
NPI: | 1720054299 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DOUGLASS | ||||||||
FirstName: | MARION | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1551 E TANGERINE RD | ||||||||
Address2: | STE. 3 | ||||||||
City: | ORO VALLEY | ||||||||
State: | AZ | ||||||||
PostalCode: | 857556213 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5209016255 | ||||||||
FaxNumber: | 5209016173 | ||||||||
Practice Location | |||||||||
Address1: | 6050 N. CORONA RD. | ||||||||
Address2: | STE 3 | ||||||||
City: | TUCSON | ||||||||
State: | AZ | ||||||||
PostalCode: | 85704 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5204698700 | ||||||||
FaxNumber: | 5204698708 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/24/2006 | ||||||||
LastUpdateDate: | 03/03/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 32713 | AZ | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.