Provider Demographics
NPI:1760419873
Name:DOUGLAS, CYNTHIA LYNN (MD)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:LYNN
Last Name:DOUGLAS
Suffix:
Gender:F
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:PO BOX 5007
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93403-5007
Mailing Address - Country:US
Mailing Address - Phone:805-710-7308
Mailing Address - Fax:
Practice Address - Street 1:3701 S HIGUERA ST
Practice Address - Street 2:STE 200
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-7462
Practice Address - Country:US
Practice Address - Phone:805-541-6033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG50091207ZC0500X, 207ZP0101X, 207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
No207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0058760Medicaid
CA00G500910Medicaid
CALAB43503FMedicaid
CAGR0058760Medicaid
CAAD9097519OtherDEA
CAA92951Medicare UPIN
CA00G500910Medicaid
CALAB43503FMedicaid