Healthcare Provider Details

I. General information

NPI: 1255866224
Provider Name (Legal Business Name): JONATHAN SAMUEL MCDOUGAL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2017
Last Update Date: 02/27/2026
Certification Date: 02/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 FRANCIS ST
BOSTON MA
02115-6106
US

IV. Provider business mailing address

75 FRANCIS ST
BOSTON MA
02115-6106
US

V. Phone/Fax

Practice location:
  • Phone: 501-733-1981
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number2020015334
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number14216229-1205
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberV5103
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD217707
License Number StateOR
# 5
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number292149
License Number StateMA
# 6
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: