MEDICARE: CAROLYN B MCDOUGALD, DO, P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	L2458	TX

General Provider Information

NPI Number	:	1710199187
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAROLYN B MCDOUGALD, DO, P.A.

Provider Business Mailing Address
First Line	:	6080 S HULEN ST
Second Line	:	SUITE 360
City	:	FT WORTH
State	:	TX
Zip	:	76132-2622
Country	:	US
Telephone Number	:	817-456-6874
Fax Number	:	866-388-2989

Provider Business Practice Location Address
First Line	:	6080 S HULEN ST
Second Line	:	SUITE 360
City	:	FT WORTH
State	:	TX
Zip	:	76132-2622
Country	:	US
Telephone Number	:	817-456-6874
Fax Number	:	866-388-2989

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. CAROLYN MCDOUGALD
Credential	:	DO
Telephone Number	:	817-456-6874

Provider Enumeration Date	:	05/05/2007
Last Update Date	:	10/11/2007

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