Provider Demographics
NPI:1780677179
Name:MCDONOUGH, FREDERICK CARL (DO)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:CARL
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 1:2010 NINE RD
Mailing Address - Street 2:
Mailing Address - City:BRADY
Mailing Address - State:TX
Mailing Address - Zip Code:76825-7210
Mailing Address - Country:US
Mailing Address - Phone:325-597-2114
Mailing Address - Fax:325-597-2155
Practice Address - Street 1:2010 NINE RD
Practice Address - Street 2:
Practice Address - City:BRADY
Practice Address - State:TX
Practice Address - Zip Code:76825-7210
Practice Address - Country:US
Practice Address - Phone:325-597-2114
Practice Address - Fax:325-597-2155
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH2586207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX120585803Medicaid
TX120585803Medicaid
TX00DQ39Medicare ID - Type Unspecified