Basic Information
Provider Information | |||||||||
NPI: | 1912224700 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DOUGLAS | ||||||||
FirstName: | ANQUENETTA | ||||||||
MiddleName: | LATOSHA | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 840853 | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752840853 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3304239399 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 7503 SURRATTS RD | ||||||||
Address2: |   | ||||||||
City: | CLINTON | ||||||||
State: | MD | ||||||||
PostalCode: | 207353358 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3018688000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/03/2010 | ||||||||
LastUpdateDate: | 05/05/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/05/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | D72594 | MD | N |   | Allopathic & Osteopathic Physicians | Anesthesiology |   | 207LC0200X | 0101252851 | VA | N |   | Allopathic & Osteopathic Physicians | Anesthesiology | Critical Care Medicine | 207L00000X | S4755 | TX | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology |   | 207L00000X | MT191339 | PA | N |   | Allopathic & Osteopathic Physicians | Anesthesiology |   |
No ID Information.