=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417135971
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MACDONALD O D P A
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2008
-----------------------------------------------------
Last Update Date | 02/07/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1122 E SR 434 SUITE 1000
-----------------------------------------------------
City | WINTER SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32708-2723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-327-5560
-----------------------------------------------------
Fax | 407-327-7873
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1122 E SR 434 SUITE 1000
-----------------------------------------------------
City | WINTER SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32708-2723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-327-5560
-----------------------------------------------------
Fax | 407-327-7873
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. EDWARD MACDONALD
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 407-327-5560
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 3489
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 3422
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------