Provider Demographics
NPI:1275510182
Name:MACGILLIVRAY, JOHN DOUGLAD (M D)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DOUGLAD
Last Name:MACGILLIVRAY
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 E 70TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-4872
Mailing Address - Country:US
Mailing Address - Phone:212-606-1896
Mailing Address - Fax:212-774-2778
Practice Address - Street 1:523 E 72ND ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4099
Practice Address - Country:US
Practice Address - Phone:212-606-1896
Practice Address - Fax:212-774-2778
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-30
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY188511207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01946854Medicaid
CT200001070Medicare ID - Type Unspecified
NY84G541Medicare ID - Type Unspecified
NY01946854Medicaid
NYG92592Medicare UPIN