Provider Demographics
NPI:1043206535
Name:MCDONOUGH, MICHAEL W (DPM)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:W
Last Name:MCDONOUGH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:595 W GRANADA BLVD
Mailing Address - Street 2:SIUTE F
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-5190
Mailing Address - Country:US
Mailing Address - Phone:386-673-2266
Mailing Address - Fax:386-676-2772
Practice Address - Street 1:595 W GRANADA BLVD
Practice Address - Street 2:SIUTE F
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-5190
Practice Address - Country:US
Practice Address - Phone:386-673-2266
Practice Address - Fax:386-676-2772
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-21
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLP0979213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL87626ZMedicare PIN
T95161Medicare UPIN
87626Medicare ID - Type Unspecified