Provider Demographics
NPI:1952405417
Name:MACDONALD, ANGELA EVERETT (OD)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:EVERETT
Last Name:MACDONALD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315A WESTERN BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-6338
Mailing Address - Country:US
Mailing Address - Phone:910-353-1011
Mailing Address - Fax:910-353-4433
Practice Address - Street 1:315A WESTERN BOULEVARD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-6338
Practice Address - Country:US
Practice Address - Phone:910-353-1011
Practice Address - Fax:910-353-4433
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2031152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC093WAOtherBCBSNC
NC5905963Medicaid
NC2474496Medicare PIN