MEDICARE: DR. GERALD W MCDOUGAL DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	7089	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	D07089	OTHER	TX	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1033241294
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GERALD W MCDOUGAL DDS

Provider Business Mailing Address
First Line	:	8015 SHOAL CREEK BLVD STE 108
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78757-8051
Country	:	US
Telephone Number	:	512-454-5219
Fax Number	:	512-323-9516

Provider Business Practice Location Address
First Line	:	8015 SHOAL CREEK BLVD STE 108
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78757-8051
Country	:	US
Telephone Number	:	512-454-5219
Fax Number	:	512-323-9516

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/12/2007
Last Update Date	:	07/08/2007

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