Healthcare Provider Details

I. General information

NPI: 1932186582
Provider Name (Legal Business Name): JAMIE L MACDOUGALL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/26/2005
Last Update Date: 07/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

828 MANHATTAN BEACH BLVD
MANHATTAN BEACH CA
90266-4931
US

IV. Provider business mailing address

828 MANHATTAN BEACH BLVD
MANHATTAN BEACH CA
90266-4931
US

V. Phone/Fax

Practice location:
  • Phone: 310-545-2900
  • Fax: 310-545-2906
Mailing address:
  • Phone: 310-545-2900
  • Fax: 310-545-2906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberG55441
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberG55441
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License NumberG55441
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberG55441
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: