Provider Demographics
NPI:1235694910
Name:MCDONALD, TERA E
Entity Type:Individual
Prefix:
First Name:TERA
Middle Name:E
Last Name:MCDONALD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 W STATE ST OFC 201202
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:OH
Mailing Address - Zip Code:43420-2577
Mailing Address - Country:US
Mailing Address - Phone:567-280-6124
Mailing Address - Fax:
Practice Address - Street 1:416 W STATE ST STE 201
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:OH
Practice Address - Zip Code:43420-2577
Practice Address - Country:US
Practice Address - Phone:567-201-2929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-06
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No172A00000XOther Service ProvidersDriver