Healthcare Provider Details

I. General information

NPI: 1487856266
Provider Name (Legal Business Name): OLIVER MCDONALD MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 12/16/2020
Certification Date: 12/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 NW 12TH AVE
MIAMI FL
33136-1005
US

IV. Provider business mailing address

1400 NW 12TH AVE
MIAMI FL
33136-1003
US

V. Phone/Fax

Practice location:
  • Phone: 305-243-9149
  • Fax:
Mailing address:
  • Phone: 305-243-3734
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License NumberMD49161
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number22145
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License NumberME147832
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberD74236
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: