Provider Demographics
NPI:1265413793
Name:MCDONALD, MICHAEL (PA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MCDONALD
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:410 SAYBROOK RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-4777
Mailing Address - Country:US
Mailing Address - Phone:860-347-4620
Mailing Address - Fax:860-346-9687
Practice Address - Street 1:410 SAYBROOK RD
Practice Address - Street 2:SUITE 201
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-4777
Practice Address - Country:US
Practice Address - Phone:860-347-4620
Practice Address - Fax:860-346-9687
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT000870363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTS82094Medicare UPIN
CT970001575Medicare ID - Type Unspecified