Provider Demographics
NPI:1659621357
Name:MCDONALD, MOLLY RAE (OD)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:RAE
Last Name:MCDONALD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20094 KENWOOD TRL
Mailing Address - Street 2:PO BOX 847
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-5404
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20094 KENWOOD TRL
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-5404
Practice Address - Country:US
Practice Address - Phone:952-469-3937
Practice Address - Fax:952-469-2132
Is Sole Proprietor?:No
Enumeration Date:2012-09-11
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN3305152W00000X, 152WC0802X, 152WP0200X, 152WS0006X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
P01484181OtherRAILROAD MEDICARE
MN00220006846OtherUNITEDHEALTHCARE
MN961571081533OtherPREFERREDONE
MN0FD80MCOtherBLUE CROSS BLUE SHIELD OF MN
MN201502OtherUCARE
MNHP153144OtherHEALTH PARTNERS
MN0004690876OtherAETNA
MN22-0006846OtherMEDICA
MN0004690876OtherAETNA