Provider Demographics
NPI:1447362090
Name:MCKIBBIN, DOUGLAS WILLIAM (MD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:WILLIAM
Last Name:MCKIBBIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 MEDICAL CENTER CIR
Mailing Address - Street 2:SUITE 308
Mailing Address - City:FISHERSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22939-2273
Mailing Address - Country:US
Mailing Address - Phone:540-932-5909
Mailing Address - Fax:540-932-5910
Practice Address - Street 1:70 MEDICAL CENTER CIR
Practice Address - Street 2:SUITE 308
Practice Address - City:FISHERSVILLE
Practice Address - State:VA
Practice Address - Zip Code:22939-2273
Practice Address - Country:US
Practice Address - Phone:540-932-5909
Practice Address - Fax:540-932-5910
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101035838174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7305117Medicaid
VAB07600Medicare UPIN
VA020000969Medicare ID - Type Unspecified