Provider Demographics
NPI:1750632048
Name:MCDONALD, MARK ZACHARY (DPT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ZACHARY
Last Name:MCDONALD
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1114 W JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65721-9164
Mailing Address - Country:US
Mailing Address - Phone:417-581-1234
Mailing Address - Fax:888-550-3518
Practice Address - Street 1:1114 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:MO
Practice Address - Zip Code:65721-9164
Practice Address - Country:US
Practice Address - Phone:417-581-1234
Practice Address - Fax:888-550-3518
Is Sole Proprietor?:No
Enumeration Date:2012-09-26
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008022379225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA4370001OtherMEDICARE PTAN