Healthcare Provider Details

I. General information

NPI: 1861479479
Provider Name (Legal Business Name): MARK C MCDONALD P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2005
Last Update Date: 07/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8700 W WATERTOWN PLANK RD ORTHOPAEDIC SURGERY
MILWAUKEE WI
53226
US

IV. Provider business mailing address

S68W15500 JANESVILLE RD
MUSKEGO WI
53150-2613
US

V. Phone/Fax

Practice location:
  • Phone: 414-805-8602
  • Fax: 414-805-7171
Mailing address:
  • Phone: 414-422-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1305-023
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: