Provider Demographics
NPI:1144223439
Name:MCDONOUGH, EUGENE J (OD)
Entity Type:Individual
Prefix:DR
First Name:EUGENE
Middle Name:J
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 1:811 MAPLE RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-3260
Mailing Address - Country:US
Mailing Address - Phone:716-648-5329
Mailing Address - Fax:716-648-3185
Practice Address - Street 1:811 MAPLE RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-3260
Practice Address - Country:US
Practice Address - Phone:716-648-5329
Practice Address - Fax:716-648-3185
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYVUT003569174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00693114Medicaid
NYD30212Medicare ID - Type Unspecified
NY00693114Medicaid