Provider Demographics
NPI:1295896116
Name:MCDONALD, RODERICK M (MD)
Entity type:Individual
Prefix:DR
First Name:RODERICK
Middle Name:M
Last Name:MCDONALD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17742 BEACH BLVD STE 330
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-6861
Mailing Address - Country:US
Mailing Address - Phone:714-847-8561
Mailing Address - Fax:714-848-1571
Practice Address - Street 1:17742 BEACH BLVD STE 330
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-6861
Practice Address - Country:US
Practice Address - Phone:714-847-8561
Practice Address - Fax:714-848-1571
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA22843174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA23266Medicare UPIN