Provider Demographics
NPI:1083177562
Name:MACDONALD, MICHAEL (HAD/HIS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MACDONALD
Suffix:
Gender:M
Credentials:HAD/HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5553 LILAC PL NE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87144-5804
Mailing Address - Country:US
Mailing Address - Phone:505-771-2353
Mailing Address - Fax:505-771-2353
Practice Address - Street 1:5553 LILAC PL NE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87144-5804
Practice Address - Country:US
Practice Address - Phone:505-235-0110
Practice Address - Fax:505-771-2353
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-10
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMHAD0898237700000X, 261QH0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
No261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM19-00152716OtherMIRACLE EAR
NM0898OtherNEW MEXICO REGULATION AND LICENSING DEPARTMENT
NMHAD0898OtherNEW MEXICO REGULATION AND LICENSING DEPARTMENT