Provider Demographics
NPI:1154374684
Name:MCDOUGAL, GUY THOMAS (OD)
Entity type:Individual
Prefix:DR
First Name:GUY
Middle Name:THOMAS
Last Name:MCDOUGAL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3228 E FOUNTAIN ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85213-5527
Mailing Address - Country:US
Mailing Address - Phone:480-854-3310
Mailing Address - Fax:480-854-1157
Practice Address - Street 1:1121 S GILBERT RD
Practice Address - Street 2:SUITE 103
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-5235
Practice Address - Country:US
Practice Address - Phone:480-854-3310
Practice Address - Fax:480-854-1157
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ691152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZT41932Medicare UPIN
AZOD691Medicare ID - Type UnspecifiedSTATE LICENSE NUMBER