Provider Demographics
NPI:1740282896
Name:MACDONALD, DAVID L (OD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:L
Last Name:MACDONALD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:266 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OLD SAYBROOK
Mailing Address - State:CT
Mailing Address - Zip Code:06475-2397
Mailing Address - Country:US
Mailing Address - Phone:860-304-4066
Mailing Address - Fax:
Practice Address - Street 1:266 MAIN ST
Practice Address - Street 2:
Practice Address - City:OLD SAYBROOK
Practice Address - State:CT
Practice Address - Zip Code:06475-2397
Practice Address - Country:US
Practice Address - Phone:860-304-4066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1007152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004060919Medicaid
CT410000348Medicare ID - Type Unspecified
CT004060919Medicaid