Provider Demographics
NPI:1679640379
Name:MACDONALD, ROBERT J (DO)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:MACDONALD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9715 PRAIRIE RDG
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:IL
Mailing Address - Zip Code:60071-9112
Mailing Address - Country:US
Mailing Address - Phone:815-678-4528
Mailing Address - Fax:
Practice Address - Street 1:9715 PRAIRIE RDG
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IL
Practice Address - Zip Code:60071-9112
Practice Address - Country:US
Practice Address - Phone:815-678-4528
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL214660 L65969Medicare ID - Type Unspecified
G82915Medicare UPIN