Provider Demographics
NPI:1982096525
Name:MCDONALD, SHANE (OD)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:MCDONALD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6985 ROSEN LAKE RD.
Mailing Address - Street 2:BOX 13
Mailing Address - City:JAFFRAY
Mailing Address - State:BRITISH COLUMBIA
Mailing Address - Zip Code:V0B1T0
Mailing Address - Country:CA
Mailing Address - Phone:503-707-0409
Mailing Address - Fax:
Practice Address - Street 1:3303 SW BOND AVE FL 11
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-4501
Practice Address - Country:US
Practice Address - Phone:503-494-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-18
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3606ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist