Provider Demographics
NPI:1417135971
Name:MACDONALD O D P A
Entity Type:Organization
Organization Name:MACDONALD O D P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:MACDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:407-327-5560
Mailing Address - Street 1:1122 E SR 434
Mailing Address - Street 2:SUITE 1000
Mailing Address - City:WINTER SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32708-2723
Mailing Address - Country:US
Mailing Address - Phone:407-327-5560
Mailing Address - Fax:407-327-7873
Practice Address - Street 1:1122 E SR 434
Practice Address - Street 2:SUITE 1000
Practice Address - City:WINTER SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32708-2723
Practice Address - Country:US
Practice Address - Phone:407-327-5560
Practice Address - Fax:407-327-7873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-07
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3422152W00000X
FL3489152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
V05836Medicare UPIN
U5168AMedicare PIN
V05837Medicare UPIN
U5169AMedicare PIN
K7973Medicare PIN