Provider Demographics
NPI:1447246947
Name:MCDONOUGH, DARIA P
Entity type:Individual
Prefix:
First Name:DARIA
Middle Name:P
Last Name:MCDONOUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4211
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32175-4211
Mailing Address - Country:US
Mailing Address - Phone:386-672-9932
Mailing Address - Fax:386-672-4201
Practice Address - Street 1:284 N HALIFAX DR
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32176-5765
Practice Address - Country:US
Practice Address - Phone:386-672-9932
Practice Address - Fax:386-672-4201
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-21
Last Update Date:2014-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLP0978213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
480014083OtherRAILROAD MEDICARE
FL340437400Medicaid
FL87625YMedicare PIN
480014083OtherRAILROAD MEDICARE
T55476Medicare UPIN
87625Medicare ID - Type Unspecified
FL5188620001Medicare NSC