Provider Demographics
NPI:1861491060
Name:MCDONALD, MICHAEL ALLEN (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ALLEN
Last Name:MCDONALD
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2548 MEMORIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ARTHUR
Mailing Address - State:TX
Mailing Address - Zip Code:77640-2825
Mailing Address - Country:US
Mailing Address - Phone:409-983-1161
Mailing Address - Fax:409-983-4933
Practice Address - Street 1:615 W COURT ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:TX
Practice Address - Zip Code:75966-3010
Practice Address - Country:US
Practice Address - Phone:409-379-8338
Practice Address - Fax:409-983-4933
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA-01009207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX451923Medicare ID - Type Unspecified
S86493Medicare UPIN