Provider Demographics
NPI:1679556229
Name:FOSSELMAN, DOUGLAS D (MD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:D
Last Name:FOSSELMAN
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 1:555 W SCHROCK RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43081-8702
Mailing Address - Country:US
Mailing Address - Phone:614-882-0708
Mailing Address - Fax:614-882-2878
Practice Address - Street 1:555 W SCHROCK RD
Practice Address - Street 2:SUITE 110
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43081-8702
Practice Address - Country:US
Practice Address - Phone:614-882-0708
Practice Address - Fax:614-882-2878
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-28
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-04-9664207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0605090Medicaid
OH0605090Medicaid
OH0571083Medicare PIN