Provider Demographics
NPI:1932618204
Name:MACDONALD, MARTINE
Entity Type:Individual
Prefix:
First Name:MARTINE
Middle Name:
Last Name:MACDONALD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 LONG ISLAND AVE
Mailing Address - Street 2:
Mailing Address - City:WYANDANCH
Mailing Address - State:NY
Mailing Address - Zip Code:11798-3015
Mailing Address - Country:US
Mailing Address - Phone:631-920-8250
Mailing Address - Fax:
Practice Address - Street 1:234 LONG ISLAND AVE
Practice Address - Street 2:
Practice Address - City:WYANDANCH
Practice Address - State:NY
Practice Address - Zip Code:11798-3015
Practice Address - Country:US
Practice Address - Phone:631-920-8250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program