Provider Demographics
NPI:1780633008
Name:MCDOUGALL, JOHN H (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:H
Last Name:MCDOUGALL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2445 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-3257
Mailing Address - Country:US
Mailing Address - Phone:217-222-9207
Mailing Address - Fax:217-222-9205
Practice Address - Street 1:2445 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-3257
Practice Address - Country:US
Practice Address - Phone:217-222-8800
Practice Address - Fax:217-641-0028
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2018-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA002541152W00000X
MOT02383152W00000X
IL046006875152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1780633008Medicaid
MO1780633008Medicaid
IL1780633008Medicaid
IL046006875Medicaid