Basic Information
| Provider Information | |||||||||
| NPI: | 1992810717 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCDONALD | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1022 LEE-ANN DRIVE NE | ||||||||
| Address2: | |||||||||
| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048861918 | ||||||||
| FaxNumber: | 7042572049 | ||||||||
| Practice Location | |||||||||
| Address1: | 1022 LEE ANN DR NE | ||||||||
| Address2: | |||||||||
| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280252911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7047864482 | ||||||||
| FaxNumber: | 7047860604 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2006 | ||||||||
| LastUpdateDate: | 08/09/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 443 | NC | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213ES0131X | 443 | NC | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot Surgery | 213EP1101X | 443 | NC | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Primary Podiatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | P01141570 | 01 | NC | RAILROAD | OTHER | 890811C | 05 | NC | MEDICAID |