Provider Demographics
NPI:1669220695
Name:MCDONOUGH, MATTHEW MICHAEL
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:MICHAEL
Last Name:MCDONOUGH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 N LEE ST APT 204
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-3243
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2817 ROCK MERRITT AVENUE
Practice Address - Street 2:
Practice Address - City:FORT LIBERTY
Practice Address - State:NC
Practice Address - Zip Code:28310-0001
Practice Address - Country:US
Practice Address - Phone:910-907-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-06
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider