Provider Demographics
NPI:1124080791
Name:MACDONALD, MARK G (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:G
Last Name:MACDONALD
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1690 UNIVERSITY AVE W
Mailing Address - Street 2:SUITE 460
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-3723
Mailing Address - Country:US
Mailing Address - Phone:651-232-2002
Mailing Address - Fax:651-232-2031
Practice Address - Street 1:1700 UNIVERSITY AVE W FL 1
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-3727
Practice Address - Country:US
Practice Address - Phone:651-232-2002
Practice Address - Fax:651-232-2031
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-06
Last Update Date:2018-10-22
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Provider Licenses
StateLicense IDTaxonomies
MN40313207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN848182200Medicaid