Healthcare Provider Details

I. General information

NPI: 1083677009
Provider Name (Legal Business Name): JOHN M MACDONALD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2006
Last Update Date: 11/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1475 NW 12TH AVE BOX 016960 M851
MIAMI FL
33136-1002
US

IV. Provider business mailing address

1475 NW 12TH AVE BOX 016960 M851
MIAMI FL
33136-1002
US

V. Phone/Fax

Practice location:
  • Phone: 305-243-8693
  • Fax: 305-243-8470
Mailing address:
  • Phone: 305-243-8693
  • Fax: 305-243-8470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberME11494
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: