Healthcare Provider Details

I. General information

NPI: 1114116506
Provider Name (Legal Business Name): MARK MCDONALD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2007
Last Update Date: 09/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11500 W OLYMPIC BLVD SUITE 426
LOS ANGELES CA
90064-1524
US

IV. Provider business mailing address

11500 W OLYMPIC BLVD SUITE 426
LOS ANGELES CA
90064-1524
US

V. Phone/Fax

Practice location:
  • Phone: 310-954-9565
  • Fax: 310-359-0467
Mailing address:
  • Phone: 310-954-9565
  • Fax: 310-359-0467

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberA112267
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: