Provider Demographics
NPI:1265279483
Name:DOUGLAS, MAXWELL
Entity type:Individual
Prefix:
First Name:MAXWELL
Middle Name:
Last Name:DOUGLAS
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 1:2235 E MCEWEN DR
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-1470
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1034 N HIGHLAND AVE STE C
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37130-2463
Practice Address - Country:US
Practice Address - Phone:615-890-4810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-15
Last Update Date:2025-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6692363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant