=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821541921
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEATHER R MACDONALD MD A MEDICAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2016
-----------------------------------------------------
Last Update Date | 01/12/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16305 SAND CANYON AVE SUITE 160
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92618-3782
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-557-0180
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5325 ALTON PKWY STE C715
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92604-8610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-857-1473
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | HEATHER R MACDONALD
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 310-403-0918
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | A75177
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------