Provider Demographics
NPI:1285254557
Name:MCDONOUGH, MICHELLE MORAN (MD)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:MORAN
Last Name:MCDONOUGH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:NICOLE
Other - Last Name:MORAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:101 MARTIN LUTHER KING DR
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-6460
Mailing Address - Country:US
Mailing Address - Phone:507-594-6500
Mailing Address - Fax:
Practice Address - Street 1:101 MARTIN LUTHER KING DR
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-6460
Practice Address - Country:US
Practice Address - Phone:507-594-6572
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-16
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN70168207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine