Basic Information
Provider Information | |||||||||
NPI: | 1801407960 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | QUEEN | ||||||||
FirstName: | DOUGLAS | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 130 SOUTHERN SCHOOL RD | ||||||||
Address2: |   | ||||||||
City: | SOMERSET | ||||||||
State: | KY | ||||||||
PostalCode: | 425013223 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6066794782 | ||||||||
FaxNumber: | 6066785296 | ||||||||
Practice Location | |||||||||
Address1: | 259 PARKERS MILL RD | ||||||||
Address2: |   | ||||||||
City: | SOMERSET | ||||||||
State: | KY | ||||||||
PostalCode: | 425013152 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6066797348 | ||||||||
FaxNumber: | 6066794097 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/12/2020 | ||||||||
LastUpdateDate: | 08/12/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/12/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 175T00000X |   |   | Y |   |   |   |   |
No ID Information.