Healthcare Provider Details

I. General information

NPI: 1144223439
Provider Name (Legal Business Name): EUGENE J. MCDONOUGH O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2005
Last Update Date: 11/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 MAPLE RD
WILLIAMSVILLE NY
14221-3260
US

IV. Provider business mailing address

811 MAPLE RD
WILLIAMSVILLE NY
14221-3260
US

V. Phone/Fax

Practice location:
  • Phone: 716-648-5329
  • Fax: 716-648-3185
Mailing address:
  • Phone: 716-648-5329
  • Fax: 716-648-3185

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberVUT003569
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: