Provider Demographics
NPI:1689677544
Name:CIFUENTES, DOUGLAS I (DO)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:I
Last Name:CIFUENTES
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 JEFFERSON AVE
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-7101
Mailing Address - Country:US
Mailing Address - Phone:419-251-1963
Mailing Address - Fax:419-872-9549
Practice Address - Street 1:1103 VILLAGE SQUARE DR
Practice Address - Street 2:STE 100
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-1762
Practice Address - Country:US
Practice Address - Phone:419-872-3213
Practice Address - Fax:419-872-9549
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-00-7147-C207R00000X
IN02005184A208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2131722Medicaid
OH2131722Medicaid
OHG97146Medicare UPIN