Basic Information
Provider Information
NPI: 1003142886
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MCDONALD
FirstName: HEATHER
MiddleName: ELIZABETH
NamePrefix:  
NameSuffix:  
Credential: D.O.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1125 VIA VERDE
Address2:  
City: SAN DIMAS
State: CA
PostalCode: 917734400
CountryCode: US
TelephoneNumber: 9095929778
FaxNumber: 9095996126
Practice Location
Address1: 1125 VIA VERDE
Address2:  
City: SAN DIMAS
State: CA
PostalCode: 917734400
CountryCode: US
TelephoneNumber: 9095929778
FaxNumber: 9095996126
Other Information
ProviderEnumerationDate: 10/28/2009
LastUpdateDate: 06/05/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
208D00000X20A10617CAY Allopathic & Osteopathic PhysiciansGeneral Practice 

No ID Information.


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