Provider Demographics
NPI:1780867747
Name:MCDONOUGH PODIATRY PA
Entity Type:Organization
Organization Name:MCDONOUGH PODIATRY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:MCDONOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:386-673-2266
Mailing Address - Street 1:595 W GRANADA BLVD
Mailing Address - Street 2:SUITE F
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-5190
Mailing Address - Country:US
Mailing Address - Phone:386-673-2266
Mailing Address - Fax:386-676-2772
Practice Address - Street 1:595 W GRANADA BLVD
Practice Address - Street 2:SUITE F
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-5190
Practice Address - Country:US
Practice Address - Phone:386-673-2266
Practice Address - Fax:386-676-2772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-13
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLP0979213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
5258470002Medicare NSC
FL87626Medicare PIN
5258470001Medicare NSC
FLAI607Medicare PIN
FLT95161Medicare UPIN