Provider Demographics
NPI:1922089218
Name:MCDOUGALL, JEFFREY A (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:A
Last Name:MCDOUGALL
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 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7125 MURRELL RD STE B
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-7999
Practice Address - Country:US
Practice Address - Phone:321-361-5587
Practice Address - Fax:321-253-3805
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME67410207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP01164150OtherRR MEDICARE
FL379617500Medicaid
FL080080567OtherRR MEDICARE
FL28970Medicare PIN