Provider Demographics
NPI:1134717911
Name:KANE, DOUGLAS GEORGE
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:GEORGE
Last Name:KANE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:613 BOSTON POST RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:CT
Mailing Address - Zip Code:06443-3059
Mailing Address - Country:US
Mailing Address - Phone:203-245-3165
Mailing Address - Fax:203-245-4226
Practice Address - Street 1:613 BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:CT
Practice Address - Zip Code:06443-3059
Practice Address - Country:US
Practice Address - Phone:203-245-4226
Practice Address - Fax:203-245-4226
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-06
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8724183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0710271OtherNABP
CT004048542Medicaid