Provider Demographics
NPI:1346273489
Name:MACDONALD, IMELDA (MD)
Entity Type:Individual
Prefix:DR
First Name:IMELDA
Middle Name:
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 1:1425 PORTLAND AVENUE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621
Mailing Address - Country:US
Mailing Address - Phone:585-922-9080
Mailing Address - Fax:
Practice Address - Street 1:1425 PORTLAND AVENUE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621
Practice Address - Country:US
Practice Address - Phone:585-922-9080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2013-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY155027207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01197819Medicaid
NYRA5617Medicare PIN
NYJ400021182Medicare PIN
NY01197819Medicaid
NYE92211Medicare UPIN