Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QG0300X | Family Doctor - Geriatric Medicine | 4301035998 | MI |
NPI | 1275519183 |
---|---|
Provider Name | Douglas A Krause |
First Address | Port Huron, MI 48060-8639 |
Second Address | Port Huron, MI 48060-8639 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/12/2005 |
Last Update Date | 03/12/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
4691650 | (05) | MI |
A76961 | (02) | MI |