Provider Demographics
NPI:1417006123
Name:MACDONALD, WILLIAM GLENN (OD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:GLENN
Last Name:MACDONALD
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:PO BOX 910
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:45177-0910
Mailing Address - Country:US
Mailing Address - Phone:937-382-4933
Mailing Address - Fax:937-383-1336
Practice Address - Street 1:2079 ROMBACH AVE.
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:OH
Practice Address - Zip Code:45177-0910
Practice Address - Country:US
Practice Address - Phone:937-382-4933
Practice Address - Fax:937-383-1336
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3359152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHT47434Medicare UPIN
OHMA0505753Medicare ID - Type Unspecified