Provider Demographics
NPI:1790742849
Name:MCDONOUGH, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:MCDONOUGH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:# L-3652
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43260-6052
Mailing Address - Country:US
Mailing Address - Phone:740-383-7927
Mailing Address - Fax:740-383-7942
Practice Address - Street 1:1040 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-6416
Practice Address - Country:US
Practice Address - Phone:740-383-7950
Practice Address - Fax:740-383-7097
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35081423M208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2333853Medicaid
OH000000233026OtherANTHEM
311098079OtherTAX ID
353077OtherSUBMITTER NO
7794409OtherAETNA
311098079OtherPPO NEXT
311098079OtherCIGNA
020052624OtherTRAVELERS MEDICARE
1402423OtherUHC
311098079OtherTAX ID
OH2333853Medicaid
OHH158840Medicare PIN