MEDICARE: PETER G. MCDOUGALL M.D.

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	207QA0000X	Adolescent Medicine (Family Medicine) Physician	E8068	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00766R	OTHER	TX	MEDICARE GROUP NUMBER

General Provider Information

NPI Number	:	1427242932
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PETER G. MCDOUGALL M.D.

Provider Business Mailing Address
First Line	:	6609 CROOKED STICK DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-4526
Country	:	US
Telephone Number	:	817-307-5101
Fax Number	:

Provider Business Practice Location Address
First Line	:	6609 CROOKED STICK DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132
Country	:	US
Telephone Number	:	817-307-5101
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. PETER GORDON MCDOUGALL
Credential	:	M.D.
Telephone Number	:	817-307-5101

Provider Enumeration Date	:	08/29/2007
Last Update Date	:	02/11/2016

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