Provider Demographics
NPI:1952353815
Name:MCDONALD, CLEMENT J
Entity Type:Individual
Prefix:
First Name:CLEMENT
Middle Name:J
Last Name:MCDONALD
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:PO BOX 78158
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46278-0158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1002 WISHARD BLVD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-2872
Practice Address - Country:US
Practice Address - Phone:317-692-2300
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01024115A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
INC24253Medicare UPIN
IN715530WWWMedicare ID - Type Unspecified