Provider Demographics
NPI:1740471259
Name:GENEVIEVE A. MAC DONALD M.D. INC.
Entity type:Organization
Organization Name:GENEVIEVE A. MAC DONALD M.D. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GENEVIEVE
Authorized Official - Middle Name:A
Authorized Official - Last Name:MAC DONALD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-906-2141
Mailing Address - Street 1:15477 VENTURA BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-3046
Mailing Address - Country:US
Mailing Address - Phone:818-906-2141
Mailing Address - Fax:800-814-8755
Practice Address - Street 1:15477 VENTURA BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-3046
Practice Address - Country:US
Practice Address - Phone:818-906-2141
Practice Address - Fax:800-814-8755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-08
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG16852208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1780740993OtherNPI TYPE 1
CA00G16852Medicaid
CAG16852OtherLICENSE NUMBER
CA850939Medicare UPIN