Healthcare Provider Details

I. General information

NPI: 1346280161
Provider Name (Legal Business Name): JOHN P MCDONOUGH III
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 07/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2223 SHADEHILL CT
TAMPA FL
33612-5024
US

IV. Provider business mailing address

2223 SHADEHILL CT
TAMPA FL
33612-5024
US

V. Phone/Fax

Practice location:
  • Phone: 813-495-4773
  • Fax:
Mailing address:
  • Phone: 813-495-4773
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN P. MCDONOUGH III
Title or Position: PRESIDENT
Credential: PH.D.
Phone: 813-495-4773