Provider Demographics
NPI:1740261734
Name:MCDONALD, JEFFREY LAYNE (CP)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:LAYNE
Last Name:MCDONALD
Suffix:
Gender:M
Credentials:CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1142 SHIPYARD BLVD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412-6439
Mailing Address - Country:US
Mailing Address - Phone:910-350-0067
Mailing Address - Fax:910-350-0065
Practice Address - Street 1:1142 SHIPYARD BLVD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28412-6439
Practice Address - Country:US
Practice Address - Phone:910-350-0067
Practice Address - Fax:910-350-0065
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7703733Medicaid
NC4184850002Medicare ID - Type UnspecifiedPROVIDER NUMBER