Healthcare Provider Details

I. General information

NPI: 1053302869
Provider Name (Legal Business Name): MCDONALD PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2005
Last Update Date: 07/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1960 TAMARACK RD
NEWARK OH
43055-1363
US

IV. Provider business mailing address

1960 TAMARACK RD
NEWARK OH
43055-1363
US

V. Phone/Fax

Practice location:
  • Phone: 740-344-8687
  • Fax: 740-522-5110
Mailing address:
  • Phone: 740-344-8687
  • Fax: 740-522-5110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35052307
License Number StateOH

VIII. Authorized Official

Name: MRS. DONNA JEAN MCDONALD
Title or Position: OWNER PHYSICIAN
Credential: MD
Phone: 740-344-8687