Provider Demographics
NPI:1225068653
Name:MACDONALD, MARCELLA A (DPM)
Entity Type:Individual
Prefix:
First Name:MARCELLA
Middle Name:A
Last Name:MACDONALD
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 MAIN STREET
Mailing Address - Street 2:SUITE 12
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06042
Mailing Address - Country:US
Mailing Address - Phone:860-649-9797
Mailing Address - Fax:860-432-9294
Practice Address - Street 1:153 MAIN STREET
Practice Address - Street 2:SUITE 12
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06042
Practice Address - Country:US
Practice Address - Phone:860-649-9797
Practice Address - Fax:860-432-9294
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2008-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000563213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTT89848Medicare UPIN
CT480000464Medicare ID - Type UnspecifiedMEDICARE