Provider Demographics
NPI:1669589974
Name:BACKOUS, DOUGLAS D (MD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:D
Last Name:BACKOUS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1205
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98371-0231
Mailing Address - Country:US
Mailing Address - Phone:253-770-9000
Mailing Address - Fax:
Practice Address - Street 1:104 27TH AVE SE
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98374-1145
Practice Address - Country:US
Practice Address - Phone:253-770-9000
Practice Address - Fax:253-770-9712
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00034718207YX0901X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & Neurotology
Provider Identifiers
StateIdentifier IDID TypeIssuer
376478OtherWA L&I
WA1045189Medicaid
WAUS5909166OtherAETNA/USHC SPECIALIST
WA0039572OtherLABOR & INDUSTRY
WABA7399OtherBLUE SHIELD
WAMD7183OtherALASKA MEDICAID
WAUS5909166OtherAETNA/USHC SPECIALIST
G28106Medicare UPIN
G28106Medicare UPIN