Provider Demographics
NPI:1497878540
Name:DR. E. L. MCDONNELL P.A
Entity Type:Organization
Organization Name:DR. E. L. MCDONNELL P.A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:MCDONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:OD, PA
Authorized Official - Phone:870-234-4444
Mailing Address - Street 1:220 N PINE
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:AR
Mailing Address - Zip Code:71753-2905
Mailing Address - Country:US
Mailing Address - Phone:870-234-4444
Mailing Address - Fax:870-234-0420
Practice Address - Street 1:220 N PINE STREET
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:AR
Practice Address - Zip Code:71753-2905
Practice Address - Country:US
Practice Address - Phone:870-234-4444
Practice Address - Fax:870-234-0420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2124152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR110154022Medicaid
AR110154022Medicaid
ARC20173Medicare UPIN
AR0500590001Medicare NSC