Healthcare Provider Details

I. General information

NPI: 1548352529
Provider Name (Legal Business Name): FRED MELVIN MCDONALD JR. ND, DOM, LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1351 STONEBRIDGE PKWY
WATKINSVILLE GA
30677-6037
US

IV. Provider business mailing address

1351 STONEBRIDGE PKWY
WATKINSVILLE GA
30677-6037
US

V. Phone/Fax

Practice location:
  • Phone: 706-769-0720
  • Fax: 706-769-8754
Mailing address:
  • Phone: 706-769-0720
  • Fax: 706-769-8754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number000162
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: