Provider Demographics
NPI:1548297328
Name:DOUGLAS, WINSTON GEORGE (MD)
Entity type:Individual
Prefix:
First Name:WINSTON
Middle Name:GEORGE
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:840 HUMBOLDT PKWY
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14211-1217
Mailing Address - Country:US
Mailing Address - Phone:716-884-8033
Mailing Address - Fax:716-884-8036
Practice Address - Street 1:840 HUMBOLDT PKWY
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14211-1217
Practice Address - Country:US
Practice Address - Phone:716-884-8033
Practice Address - Fax:716-884-8036
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-27
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY208258-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01804580Medicaid
NY0409592OtherINDEPENDENT HEALTH
NY00010311504OtherUNIVERA
NY000524891004OtherBLUECROSS BLUESHIELD
NYP00052855OtherMEDICARE RAIL ROAD
NYP00052855OtherMEDICARE RAIL ROAD
NYAA1704Medicare PIN