Provider Demographics
NPI:1528056694
Name:DOUGLAS, DALE E (MD)
Entity type:Individual
Prefix:DR
First Name:DALE
Middle Name:E
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 ENGLAND DR
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-0924
Mailing Address - Country:US
Mailing Address - Phone:931-528-7531
Mailing Address - Fax:931-520-0413
Practice Address - Street 1:701 COUNTY SERVICES DR
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-4338
Practice Address - Country:US
Practice Address - Phone:931-528-2531
Practice Address - Fax:931-526-7451
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD 008036208600000X
TNMD8036208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNB03137Medicare UPIN