Basic Information
| Provider Information | |||||||||
| NPI: | 1922103480 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCDONALD | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | WHITFIELD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 CYPRESS ST | ||||||||
| Address2: | |||||||||
| City: | BROOKLINE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024456002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8573070896 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1153 CENTRE ST | ||||||||
| Address2: | SUITE 4420 | ||||||||
| City: | JAMAICA PLAIN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021303446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6179834570 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2006 | ||||||||
| LastUpdateDate: | 07/20/2012 | ||||||||
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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 | 208800000X | 77817 | MA | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 110059738A | 05 | MA | MEDICAID |