Provider Demographics
NPI:1427242932
Name:PETER G. MCDOUGALL M.D.
Entity type:Organization
Organization Name:PETER G. MCDOUGALL M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:GORDON
Authorized Official - Last Name:MCDOUGALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-307-5101
Mailing Address - Street 1:6609 CROOKED STICK DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-4526
Mailing Address - Country:US
Mailing Address - Phone:817-307-5101
Mailing Address - Fax:
Practice Address - Street 1:6609 CROOKED STICK DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132
Practice Address - Country:US
Practice Address - Phone:817-307-5101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-29
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE8068207QA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00766ROtherMEDICARE GROUP NUMBER
TX8552N0Medicare PIN
TXB24730Medicare UPIN