Provider Demographics
NPI:1558697599
Name:MCDONOUGH, PATRICK (DO)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:
Last Name:MCDONOUGH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1735 27TH ST STE B06
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-2681
Mailing Address - Country:US
Mailing Address - Phone:740-356-6942
Mailing Address - Fax:740-356-7851
Practice Address - Street 1:1805 27TH ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-2640
Practice Address - Country:US
Practice Address - Phone:740-356-8117
Practice Address - Fax:740-353-1214
Is Sole Proprietor?:No
Enumeration Date:2009-10-27
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA44782085R0202X
OH58.0030402085R0202X
OH340097682085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH58.003040OtherDO TRAINIG CERTIFICATE
OH0103829Medicaid
KY7100371950Medicaid