MEDICARE: DR. PETER GORDON 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	207QA0505X	Adult Medicine Physician	E8068	TX
2	207Q00000X	Family Medicine Physician	E8068	TX

General Provider Information

NPI Number	:	1548264948
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PETER GORDON MCDOUGALL M.D.

Provider Business Mailing Address
First Line	:	6609 CROOKED STICK DR
Second Line	:	STE 290
City	:	FORT WORTH
State	:	TX
Zip	:	76132
Country	:	US
Telephone Number	:	817-307-5101
Fax Number	:

Provider Business Practice Location Address
First Line	:	6609 CROOKED STICK DR
Second Line	:	STE 290
City	:	FORT WORTH
State	:	TX
Zip	:	76132
Country	:	US
Telephone Number	:	817-307-5101
Fax Number	:

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

Provider Enumeration Date	:	06/13/2005
Last Update Date	:	11/11/2016

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