Provider Demographics
NPI:1265579478
Name:MACDONALD, TINA (OD)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:MACDONALD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:795 E 2ND ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91766-2007
Mailing Address - Country:US
Mailing Address - Phone:909-706-3899
Mailing Address - Fax:909-469-5228
Practice Address - Street 1:795 E 2ND ST
Practice Address - Street 2:SUITE 2
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91766-2007
Practice Address - Country:US
Practice Address - Phone:909-706-3899
Practice Address - Fax:909-469-8640
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9911T152W00000X
CAOPT9911 TPG152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWOP9911AOtherMEDICARE PTAN CPS
CACB269766OtherMEDICARE PTAN WUECI