Provider Demographics
NPI:1861431207
Name:DOUGLAS, ANNETTE C (MD)
Entity type:Individual
Prefix:
First Name:ANNETTE
Middle Name:C
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANNETTE
Other - Middle Name:C
Other - Last Name:AKINWANDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11995 SINGLETREE LN
Mailing Address - Street 2:STE 500
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-5347
Mailing Address - Country:US
Mailing Address - Phone:952-595-1301
Mailing Address - Fax:612-294-4903
Practice Address - Street 1:8714 SARGENT CREEK LN
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-1376
Practice Address - Country:US
Practice Address - Phone:952-595-1100
Practice Address - Fax:612-294-4903
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010566512085N0700X, 2085R0202X, 2085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00043714OtherRAILROAD MEDICARE
IN219950EEMedicare PIN
INP00742706OtherRAILROAD MEDICARE
ING35474Medicare UPIN
IN200410240Medicaid
IN000000250292OtherANTHEM BCBS
IN959090M1Medicare PIN