Provider Demographics
NPI:1215038906
Name:MACDONALD, JOHN S (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:S
Last Name:MACDONALD
Suffix:
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 1:110 W HIGHAM ST
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:MI
Mailing Address - Zip Code:48879-1559
Mailing Address - Country:US
Mailing Address - Phone:989-224-0646
Mailing Address - Fax:989-224-0929
Practice Address - Street 1:110 W HIGHAM ST
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:MI
Practice Address - Zip Code:48879-1559
Practice Address - Country:US
Practice Address - Phone:989-224-0646
Practice Address - Fax:989-224-0929
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301038398207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI10 2116963Medicaid
MI10 2116963Medicaid
MIP50220001Medicare PIN
MI0190011Medicare ID - Type Unspecified