Provider Demographics
NPI:1144900572
Name:DOUGLAS, MYRON B SR
Entity type:Individual
Prefix:MR
First Name:MYRON
Middle Name:B
Last Name:DOUGLAS
Suffix:SR
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 1:406 BRUSHY BAYOU BLVD
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-6900
Mailing Address - Country:US
Mailing Address - Phone:318-470-3585
Mailing Address - Fax:
Practice Address - Street 1:406 BRUSHY BAYOU BLVD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-6900
Practice Address - Country:US
Practice Address - Phone:318-470-3585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-20
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA332900000X, 343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No332900000XSuppliersNon-Pharmacy Dispensing Site