Basic Information
| Provider Information | |||||||||
| NPI: | 1891723755 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCDONALD | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14050 NW 14TH ST | ||||||||
| Address2: | SUITE 190 | ||||||||
| City: | SUNRISE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333232865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004243672 | ||||||||
| FaxNumber: | 9543773042 | ||||||||
| Practice Location | |||||||||
| Address1: | 630 E RIVER ST | ||||||||
| Address2: | |||||||||
| City: | ELYRIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440355902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403297500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 207P00000X | 35-06-0485-M | OH | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0856211 | 05 | OH | MEDICAID |