Individual
DOUGLAS E PROVOST
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
161 CAREY RD, QUEENSBURY, NY 12804-7821
(518) 824-8610
Mailing address
9 CAREY RD, QUEENSBURY, NY 12804-7880
(518) 761-0300
(518) 824-2388
Taxonomy
Speciality
Code
Description
License number
State
207V00000X
Obstetrics & Gynecology Physician
Primary
134188
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000405036002
BLUE SHIELD
—
05
—
00460999
—
NY
01
—
10001652
CDPHP
—
01
—
16454
MVP
—
01
—
DP077E5610
EBS
—
Enumeration date
10/19/2005
Last updated
12/22/2015
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