Provider Demographics
NPI:1871558353
Name:MCKEAG, DOUGLAS BRUCE (MD, MS)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:BRUCE
Last Name:MCKEAG
Suffix:
Gender:M
Credentials:MD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4411 SW VERMONT ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-1020
Mailing Address - Country:US
Mailing Address - Phone:503-494-9992
Mailing Address - Fax:
Practice Address - Street 1:4411 SW VERMONT ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-1020
Practice Address - Country:US
Practice Address - Phone:503-494-9992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2014-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD167303207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200259190Medicaid
INP00800740OtherRR MEDICARE
IN715530DRRRMedicare PIN