Provider Demographics
NPI:1881600633
Name:MACDONALD, ROBERT JAMES (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:JAMES
Last Name:MACDONALD
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 1:139 HAZARD AVE
Mailing Address - Street 2:SUITE 7
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082-4585
Mailing Address - Country:US
Mailing Address - Phone:860-763-4465
Mailing Address - Fax:
Practice Address - Street 1:139 HAZARD AVE
Practice Address - Street 2:SUITE 7
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-4585
Practice Address - Country:US
Practice Address - Phone:860-763-4465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA424532084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Not Answered2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3156460Medicaid
MA3156460Medicaid
Y02803Medicare ID - Type Unspecified