Provider Demographics
NPI:1932186582
Name:MACDOUGALL, JAMIE L (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMIE
Middle Name:L
Last Name:MACDOUGALL
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 1:828 MANHATTAN BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-4931
Mailing Address - Country:US
Mailing Address - Phone:310-545-2900
Mailing Address - Fax:310-545-2906
Practice Address - Street 1:828 MANHATTAN BEACH BLVD
Practice Address - Street 2:
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-4931
Practice Address - Country:US
Practice Address - Phone:310-545-2900
Practice Address - Fax:310-545-2906
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-26
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG55441207N00000X, 207ND0900X, 207NP0225X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG55441OtherSTATE LICENSE NUMBER
CAG55441Medicare ID - Type Unspecified
CAA52953Medicare UPIN