Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207VG0400X | Gynecologist | 018012 | GA |
NPI | 1134342744 |
---|---|
Provider Name | Beverly Goode Douglas |
First Address | Atlanta, GA 30324-2700 |
Second Address | Atlanta, GA 30324-2700 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/04/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
D39761 | (02) |