Provider Demographics
NPI:1053574137
Name:DOUGLAS, ROBERT JAMES (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:JAMES
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2510 INAGUA AVE
Mailing Address - Street 2:N/A
Mailing Address - City:COCONUT GROVE
Mailing Address - State:FL
Mailing Address - Zip Code:33133-3812
Mailing Address - Country:US
Mailing Address - Phone:208-989-4991
Mailing Address - Fax:
Practice Address - Street 1:13865 LOCUST LN
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-9367
Practice Address - Country:US
Practice Address - Phone:208-989-4991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME13225174400000X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFDO684109OtherDEA