Provider Demographics
NPI:1114075892
Name:MCDONALD, MARK JEFFREY (ATC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JEFFREY
Last Name:MCDONALD
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:15777 NORTHLINE RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195-2385
Mailing Address - Country:US
Mailing Address - Phone:734-246-8125
Mailing Address - Fax:734-246-8113
Practice Address - Street 1:15777 NORTHLINE RD
Practice Address - Street 2:SUITE 102
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2385
Practice Address - Country:US
Practice Address - Phone:734-246-8125
Practice Address - Fax:734-246-8113
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer