Provider Demographics
NPI:1902914963
Name:MCDONALD, WILLIAM D (DPM)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:D
Last Name:MCDONALD
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4722 QUAIL LAKES DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-5256
Mailing Address - Country:US
Mailing Address - Phone:209-476-0675
Mailing Address - Fax:209-476-9389
Practice Address - Street 1:4722 QUAIL LAKES DR
Practice Address - Street 2:SUITE A
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-5256
Practice Address - Country:US
Practice Address - Phone:209-476-0675
Practice Address - Fax:209-476-9389
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3287213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ28592ZOtherMEDICARE - ID
CAGRE001670Medicaid
CAE3287OtherSTATE LICENSE #
CAGRE001670Medicaid
CAE3287OtherSTATE LICENSE #
CAZZZ28592ZOtherMEDICARE - ID