Healthcare Provider Details

I. General information

NPI: 1699356386
Provider Name (Legal Business Name): TIMOTHY JOHN MCDONALD OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2021
Last Update Date: 12/10/2024
Certification Date: 12/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5961 S LOS ALTOS PKWY STE 101
SPARKS NV
89436-2501
US

IV. Provider business mailing address

5961 S LOS ALTOS PKWY STE 101
SPARKS NV
89436-2501
US

V. Phone/Fax

Practice location:
  • Phone: 775-359-2020
  • Fax:
Mailing address:
  • Phone: 775-359-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1221
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD61127386
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: