Provider Demographics
NPI:1124393061
Name:MCDONNELL, EDMOND J JR (MD)
Entity Type:Individual
Prefix:DR
First Name:EDMOND
Middle Name:J
Last Name:MCDONNELL
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1061 HARMON AVENUE
Mailing Address - Street 2:
Mailing Address - City:FORT STEWART
Mailing Address - State:GA
Mailing Address - Zip Code:31314-5674
Mailing Address - Country:US
Mailing Address - Phone:912-435-6633
Mailing Address - Fax:
Practice Address - Street 1:1061 HARMON AVENUE
Practice Address - Street 2:
Practice Address - City:FORT STEWART
Practice Address - State:GA
Practice Address - Zip Code:31314-5674
Practice Address - Country:US
Practice Address - Phone:912-435-6633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-10
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0029009207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology