Provider Demographics
NPI:1295823300
Name:MCDONALD, GARY DALLAS (OD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:DALLAS
Last Name:MCDONALD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:875 CLARK STREET
Mailing Address - Street 2:SUITE A
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765
Mailing Address - Country:US
Mailing Address - Phone:407-366-7655
Mailing Address - Fax:407-366-4129
Practice Address - Street 1:875 CLARK STREET
Practice Address - Street 2:SUITE A
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765
Practice Address - Country:US
Practice Address - Phone:407-366-7655
Practice Address - Fax:407-366-4129
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC002292152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U27671AMedicare UPIN
19483Medicare ID - Type Unspecified