Provider Demographics
NPI:1679576516
Name:DOUGLAS, MARK JASON (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:JASON
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2880 DAUPHIN ST
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36606-2457
Mailing Address - Country:US
Mailing Address - Phone:251-473-1900
Mailing Address - Fax:251-470-8943
Practice Address - Street 1:2880 DAUPHIN ST
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36606-2457
Practice Address - Country:US
Practice Address - Phone:251-473-1900
Practice Address - Fax:251-470-8943
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AL00020396207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51506459OtherBLUE CROSS AL PROV #
AL7070250OtherAETNA PROVIDER #
MS00124755Medicaid
AL51506758OtherBLUE CROSS AL PROV #
ALH07553OtherHEALTHSPRING PROVIDER #
AL51502488OtherBLUE CROSS OF AL PROV #
AL51531041OtherBLUE CROSS AL PROV #
AL51536524OtherBLUE CROSS AL PROV #
AL0810439OtherUNITED HEALTHCARE PROV #
AL51505297OtherBLUE CROSS OF AL PROV #
AL51506756OtherBLUE CROSS AL PROV #
AL51505297OtherBLUE CROSS OF AL PROV #