Provider Demographics
NPI:1770542508
Name:MCDONNELL, EDWARD LEE (OD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:LEE
Last Name:MCDONNELL
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 1:13 TANGLEWOOD
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:AR
Mailing Address - Zip Code:71753-4382
Mailing Address - Country:US
Mailing Address - Phone:870-234-5589
Mailing Address - Fax:
Practice Address - Street 1:220 N PINE
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:AR
Practice Address - Zip Code:71753-2905
Practice Address - Country:US
Practice Address - Phone:870-234-4444
Practice Address - Fax:870-234-0420
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2124152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR110154022Medicaid
AR48144Medicare UPIN
ART20173Medicare UPIN
AR0500590001Medicare NSC