Provider Demographics
NPI:1063602654
Name:MCDONALD, NEYSA J
Entity type:Individual
Prefix:
First Name:NEYSA
Middle Name:J
Last Name:MCDONALD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 ROBBINS ST
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-2652
Mailing Address - Country:US
Mailing Address - Phone:203-755-2999
Mailing Address - Fax:203-755-6782
Practice Address - Street 1:160 ROBBINS ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2652
Practice Address - Country:US
Practice Address - Phone:203-755-2999
Practice Address - Fax:203-755-6782
Is Sole Proprietor?:No
Enumeration Date:2007-07-30
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT045472208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT2V9701OtherHEALTHNET
CTP3847136OtherOXFORD
CT010045472CT01OtherBLUECROSS BLUESHIELD
CT045472OtherCONNECTICARE