Provider Demographics
NPI:1750703765
Name:DOUGLAS, CORNELIUS
Entity type:Individual
Prefix:
First Name:CORNELIUS
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2103 NW 50TH ST
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-3253
Mailing Address - Country:US
Mailing Address - Phone:405-246-5423
Mailing Address - Fax:
Practice Address - Street 1:2103 NW 50TH ST
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-3253
Practice Address - Country:US
Practice Address - Phone:405-246-5423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-09
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor