Provider Demographics
NPI:1568635357
Name:MCDONOUGH, RYAN (DO)
Entity Type:Individual
Prefix:DR
First Name:RYAN
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:PO BOX 200149
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99520-0149
Mailing Address - Country:US
Mailing Address - Phone:907-561-3211
Mailing Address - Fax:
Practice Address - Street 1:2490 S WOODWORTH LOOP STE 250
Practice Address - Street 2:
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645-7407
Practice Address - Country:US
Practice Address - Phone:907-561-3211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-11
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ4632207RC0000X
NMA-2091-17207RC0000X
AK144406207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1697729Medicaid