Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0700X | Prosthodontist | IL |
NPI | 1003938663 |
---|---|
Provider Name | Dr. Robert Duane Douglas |
First Address | East Alton, IL 62024-2086 |
Second Address | East Alton, IL 62024-2086 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/04/2007 |
Last Update Date | 08/07/2007 |