Provider Demographics
NPI:1417069089
Name:MCDONOUGH, DENISE M (MD)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:M
Last Name:MCDONOUGH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4535 NORTHERN SKY DR
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-8538
Mailing Address - Country:US
Mailing Address - Phone:701-712-3000
Mailing Address - Fax:701-712-3005
Practice Address - Street 1:4535 NORTHERN SKY DR
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-8538
Practice Address - Country:US
Practice Address - Phone:701-712-3000
Practice Address - Fax:701-712-3005
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND7470207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1454905Medicaid
ND18975Medicaid
NDN722630Medicare PIN
NDN719487Medicare PIN
NDG35270Medicare UPIN