Provider Demographics
NPI:1376857060
Name:MACDOUGALL, BRADLEY (PT)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:MACDOUGALL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 DOE WHISPER WAY
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78738-7085
Mailing Address - Country:US
Mailing Address - Phone:512-265-6182
Mailing Address - Fax:
Practice Address - Street 1:406 DOE WHISPER WAY
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78738-7085
Practice Address - Country:US
Practice Address - Phone:512-265-6182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-05
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36927208100000X
TX1316453208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation