Provider Demographics
NPI:1326158619
Name:MACDONALD, HEATHER R (MD)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:R
Last Name:MACDONALD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1510 SAN PABLO ST
Mailing Address - Street 2:SUITE 514
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-5324
Mailing Address - Country:US
Mailing Address - Phone:323-865-3000
Mailing Address - Fax:323-442-6798
Practice Address - Street 1:1510 SAN PABLO ST
Practice Address - Street 2:SUITE 514
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-5324
Practice Address - Country:US
Practice Address - Phone:323-865-3000
Practice Address - Fax:323-442-6798
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2013-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA75177207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A751770OtherBLUE SHIELD PIN
CA00A751770C29OtherCAL OPTIMA
CA00A751770Medicaid
CAWA75177AMedicare PIN
CAI62016Medicare UPIN