Provider Demographics
NPI:1730113424
Name:DOUGLAS, MICHELLE L (DO)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 N BROADWAY UNIT 707
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-6032
Mailing Address - Country:US
Mailing Address - Phone:773-791-2444
Mailing Address - Fax:
Practice Address - Street 1:34 MAPLE ST
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06850-3894
Practice Address - Country:US
Practice Address - Phone:203-852-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2025-05-31
Deactivation Date:2025-04-27
Deactivation Code:
Reactivation Date:2025-05-15
Provider Licenses
StateLicense IDTaxonomies
MA295030207V00000X
CT72895207V00000X
MEDO3433207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology