Provider Demographics
NPI:1679986277
Name:DOUGLAS, STEPHANIE (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 BROADWAY STREET, MC: 6342
Mailing Address - Street 2:PAVILION C, 4TH FLOOR
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94063-3132
Mailing Address - Country:US
Mailing Address - Phone:650-721-7669
Mailing Address - Fax:650-721-3470
Practice Address - Street 1:450 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94063-3132
Practice Address - Country:US
Practice Address - Phone:650-723-5643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-11
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021025372208100000X
IN01084127A208D00000X
MAETL-6027208D00000X
CA1985222081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice