Basic Information
| Provider Information | |||||||||
| NPI: | 1104846815 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCDONALD | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8 MIRROR LAKE DR | ||||||||
| Address2: | STE A | ||||||||
| City: | ORMOND BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321743101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3866732500 | ||||||||
| FaxNumber: | 3866733204 | ||||||||
| Practice Location | |||||||||
| Address1: | 8 MIRROR LAKE DR | ||||||||
| Address2: | STE A | ||||||||
| City: | ORMOND BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321743101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3866732500 | ||||||||
| FaxNumber: | 3866733204 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 09/27/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | ME0070742 | FL | N | Other Service Providers | Specialist | 2084D0003X | ME070742 | FL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Diagnostic Neuroimaging |
ID Information
| ID | Type | State | Issuer | Description | 250565700 | 05 | FL | MEDICAID |