Provider Demographics
NPI:1255759031
Name:MCDONALD, MAXWELL JR
Entity type:Individual
Prefix:
First Name:MAXWELL
Middle Name:
Last Name:MCDONALD
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25 CONRAN DR STE B
Practice Address - Street 2:
Practice Address - City:COOPERSVILLE
Practice Address - State:MI
Practice Address - Zip Code:49404-1366
Practice Address - Country:US
Practice Address - Phone:616-267-7860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-31
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101020884207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine