Provider Demographics
NPI:1790379204
Name:MCDONALD, MICHAEL J
Entity type:Individual
Prefix:
First Name:MICHAEL
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 1:5102 WHITEHALL DR
Mailing Address - Street 2:
Mailing Address - City:CLIFTON HEIGHTS
Mailing Address - State:PA
Mailing Address - Zip Code:19018-1219
Mailing Address - Country:US
Mailing Address - Phone:215-680-5111
Mailing Address - Fax:
Practice Address - Street 1:705 BATTLEFIELD BLVD N
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-4901
Practice Address - Country:US
Practice Address - Phone:757-547-0688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-24
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101275839207Q00000X
VA0102207477208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine