Healthcare Provider Details

I. General information

NPI: 1457823536
Provider Name (Legal Business Name): JAMES EDWARD MCDONOUGH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2018
Last Update Date: 05/23/2023
Certification Date: 05/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 N INDIAN CANYON DR
PALM SPRINGS CA
92262-4872
US

IV. Provider business mailing address

21562 HONEYSUCKLE ST
TRABUCO CANYON CA
92679-3475
US

V. Phone/Fax

Practice location:
  • Phone: 949-292-7348
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number20416
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberT4975
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: