=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558357913
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERIC CLYDE MCDONALD M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 34520 BOB WILSON DR NAVAL MEDICAL CENTER SAN DIEGO
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92134-2098
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-532-8275
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4143 SUNSET RD
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92103-1144
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-297-7088
-----------------------------------------------------
Fax | 619-297-6638
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | G67352
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------