Provider Demographics
NPI:1356445514
Name:MACDONALD, BRENT BRUCE (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:BRUCE
Last Name:MACDONALD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6201 GREENLEIGH AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLE RIVER
Mailing Address - State:MD
Mailing Address - Zip Code:21220-2004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4924 CAMPBELL BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21236-5908
Practice Address - Country:US
Practice Address - Phone:443-442-2300
Practice Address - Fax:443-442-2330
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD47105207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD937101000Medicaid
582ZMedicare ID - Type Unspecified
MD937101000Medicaid