Healthcare Provider Details

I. General information

NPI: 1487726469
Provider Name (Legal Business Name): KELLY M MACDONALD OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 01/08/2020
Certification Date: 01/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 W HOLLIS ST
NASHUA NH
03062-1358
US

IV. Provider business mailing address

505 W HOLLIS ST
NASHUA NH
03062-1358
US

V. Phone/Fax

Practice location:
  • Phone: 603-882-0311
  • Fax: 603-386-0046
Mailing address:
  • Phone: 603-882-0311
  • Fax: 603-386-0046

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0721
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: