Healthcare Provider Details

I. General information

NPI: 1124080791
Provider Name (Legal Business Name): MARK G MACDONALD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 10/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 UNIVERSITY AVE W FL 1
SAINT PAUL MN
55104-3727
US

IV. Provider business mailing address

1690 UNIVERSITY AVE W SUITE 460
SAINT PAUL MN
55104-3723
US

V. Phone/Fax

Practice location:
  • Phone: 651-232-2002
  • Fax: 651-232-2031
Mailing address:
  • Phone: 651-232-2002
  • Fax: 651-232-2031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number40313
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: