Healthcare Provider Details

I. General information

NPI: 1053501320
Provider Name (Legal Business Name): TERENCE J MCDONNELL MD PROFESSIONAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2007
Last Update Date: 10/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2999 REGENT STREET SUITE 710
BERKELEY CA
94705-2117
US

IV. Provider business mailing address

2999 REGENT STREET SUITE 710
BERKELEY CA
94705-2117
US

V. Phone/Fax

Practice location:
  • Phone: 510-841-1266
  • Fax: 510-841-0423
Mailing address:
  • Phone: 510-841-1266
  • Fax: 510-841-0423

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberC326600
License Number StateCA

VIII. Authorized Official

Name: MR. TERENCE J MCDONNELL
Title or Position: PRESIDENT
Credential: M.D.
Phone: 510-841-1266