Provider Demographics
NPI:1811088594
Name:MCDONALD, MARTIN (DO)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:MCDONALD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:84 ADAMS RD
Mailing Address - Street 2:
Mailing Address - City:WAPPAPELLO
Mailing Address - State:MO
Mailing Address - Zip Code:63966-8247
Mailing Address - Country:US
Mailing Address - Phone:573-222-8820
Mailing Address - Fax:
Practice Address - Street 1:2480 THREE RIVERS BLVD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-2318
Practice Address - Country:US
Practice Address - Phone:573-686-5564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2010-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MODOR9E27207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOA10666Medicare UPIN