Provider Demographics
NPI:1063468700
Name:MCDONOUGH, JAMES S
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:S
Last Name:MCDONOUGH
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 1:455 W WARREN AVE
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-4002
Mailing Address - Country:US
Mailing Address - Phone:407-262-2220
Mailing Address - Fax:407-834-5011
Practice Address - Street 1:455 W WARREN AVE
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-4002
Practice Address - Country:US
Practice Address - Phone:407-262-2220
Practice Address - Fax:407-834-5011
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2011-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME915622084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL271252100Medicaid
FL271252100Medicaid
FLU4014YMedicare PIN
FLU4014ZMedicare PIN
FLU4014XMedicare PIN