Provider Demographics
NPI:1053694851
Name:MCCAFFERTY, DOUGLAS E (PA)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:E
Last Name:MCCAFFERTY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3170 KETTERING BLVD
Mailing Address - Street 2:BUILDING B 3RD FLOOR
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1924
Mailing Address - Country:US
Mailing Address - Phone:937-991-3188
Mailing Address - Fax:937-223-9811
Practice Address - Street 1:9000 N MAIN ST
Practice Address - Street 2:STE 227
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415-1180
Practice Address - Country:US
Practice Address - Phone:937-832-4773
Practice Address - Fax:937-832-2986
Is Sole Proprietor?:No
Enumeration Date:2011-09-28
Last Update Date:2022-01-18
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OH50.00618363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0067821Medicaid
OH0067821Medicaid