Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208000000X | Pediatrician | 159823 | MA |
Y | 2084N0402X | Child Neurologist | 159823 | MA |
NPI | 1124017975 |
---|---|
Provider Name | Dr. Laurie M Douglass |
First Address | Boston, MA 02118-2371 |
Second Address | Boston, MA 02118-2526 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/10/2005 |
Last Update Date | 28/10/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
110061538A | (05) | MA |
G94507 | (02) |