Provider Demographics
NPI:1710199187
Name:CAROLYN B MCDOUGALD, DO, P.A.
Entity Type:Organization
Organization Name:CAROLYN B MCDOUGALD, DO, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDOUGALD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:817-456-6874
Mailing Address - Street 1:6080 S HULEN ST
Mailing Address - Street 2:SUITE 360
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-2622
Mailing Address - Country:US
Mailing Address - Phone:817-456-6874
Mailing Address - Fax:866-388-2989
Practice Address - Street 1:6080 S HULEN ST
Practice Address - Street 2:SUITE 360
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-2622
Practice Address - Country:US
Practice Address - Phone:817-456-6874
Practice Address - Fax:866-388-2989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-05
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL2458207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXI05247Medicare UPIN
TX00609WMedicare ID - Type Unspecified