Provider Demographics
NPI:1477857266
Name:MACDONALD, TENNYSON SCOTT
Entity Type:Individual
Prefix:
First Name:TENNYSON
Middle Name:SCOTT
Last Name:MACDONALD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2082 NEWBURY RD STE 14
Mailing Address - Street 2:
Mailing Address - City:NEWBURY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91320-3368
Mailing Address - Country:US
Mailing Address - Phone:805-498-4344
Mailing Address - Fax:
Practice Address - Street 1:2975 SYCAMORE DR
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-1201
Practice Address - Country:US
Practice Address - Phone:805-955-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-07
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA94542278P3900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2278P3900XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, CertifiedNeonatal/Pediatrics