Provider Demographics
NPI:1275905416
Name:MCDONALD, TRAVIS
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:MCDONALD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:TYNDALL
Mailing Address - State:SD
Mailing Address - Zip Code:57066-2217
Mailing Address - Country:US
Mailing Address - Phone:605-661-2296
Mailing Address - Fax:
Practice Address - Street 1:1200 W UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:MITCHELL
Practice Address - State:SD
Practice Address - Zip Code:57301-4358
Practice Address - Country:US
Practice Address - Phone:605-661-2296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-27
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program