Provider Demographics
NPI:1285609313
Name:MCDOUGALL, ERIC C (MD)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:C
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 1:3920 S 1100 EAST
Mailing Address - Street 2:STE 220
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124
Mailing Address - Country:US
Mailing Address - Phone:801-268-2584
Mailing Address - Fax:801-262-1168
Practice Address - Street 1:3920 S 1100 EAST
Practice Address - Street 2:STE 220
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124
Practice Address - Country:US
Practice Address - Phone:801-268-2584
Practice Address - Fax:801-262-1168
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3726131205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870573947004Medicaid
UT870573947004Medicaid