Provider Demographics
NPI:1578859872
Name:MCDONOUGH, KELLY (DO)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MCDONOUGH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 DUDLEY ST
Mailing Address - Street 2:PHO OFFICE
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-2401
Mailing Address - Country:US
Mailing Address - Phone:401-274-1122
Mailing Address - Fax:401-453-7597
Practice Address - Street 1:101 DUDLEY ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905-2401
Practice Address - Country:US
Practice Address - Phone:401-274-1122
Practice Address - Fax:401-453-7597
Is Sole Proprietor?:No
Enumeration Date:2011-06-24
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA258025207P00000X
RILP02223390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program