=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740253301
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEROME MICHAEL MCDONALD MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2006
-----------------------------------------------------
Last Update Date | 09/26/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1901 N CALIFORNIA ST
-----------------------------------------------------
City | STOCKTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95204-6005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-946-6800
-----------------------------------------------------
Fax | 209-946-6805
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3400 DATA DR ATTENTION: CREDENTIALING AND PAYER ENROLLMENT DEPT
-----------------------------------------------------
City | RANCHO CORDOVA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95670
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208G00000X
-----------------------------------------------------
Taxonomy Name | Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
-----------------------------------------------------
License Number | C52651
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------