Provider Demographics
NPI:1063504108
Name:MCDONOUGH, BRETT DAVID (OD)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:DAVID
Last Name:MCDONOUGH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 21821
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37424-0821
Mailing Address - Country:US
Mailing Address - Phone:423-899-9125
Mailing Address - Fax:423-899-9030
Practice Address - Street 1:2020 GUNBARREL ROAD
Practice Address - Street 2:SUITE 100E
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:34742-2663
Practice Address - Country:US
Practice Address - Phone:423-899-9125
Practice Address - Fax:423-899-9030
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNODT1825152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
10025073OtherPHP
TN3941806Medicaid
4035668OtherBCBS
3941806Medicare ID - Type Unspecified
4035668OtherBCBS