MEDICARE: DR. JAMIE L MACDOUGALL MD

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	207N00000X	Dermatology Physician	G55441	CA
2	207ND0900X	Dermatopathology Physician	G55441	CA
3	207NP0225X	Pediatric Dermatology Physician	G55441	CA
4	207NS0135X	Procedural Dermatology Physician	G55441	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G55441	OTHER	CA	STATE LICENSE NUMBER

General Provider Information

NPI Number	:	1932186582
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAMIE L MACDOUGALL MD

Provider Business Mailing Address
First Line	:	828 MANHATTAN BEACH BLVD
Second Line	:
City	:	MANHATTAN BEACH
State	:	CA
Zip	:	90266-4931
Country	:	US
Telephone Number	:	310-545-2900
Fax Number	:	310-545-2906

Provider Business Practice Location Address
First Line	:	828 MANHATTAN BEACH BLVD
Second Line	:
City	:	MANHATTAN BEACH
State	:	CA
Zip	:	90266-4931
Country	:	US
Telephone Number	:	310-545-2900
Fax Number	:	310-545-2906

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

Provider Enumeration Date	:	12/26/2005
Last Update Date	:	07/22/2009

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