Provider Demographics
NPI:1215901764
Name:MACDONALD, CHARLES C II (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:C
Last Name:MACDONALD
Suffix:II
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1333 ASHBURY CIR
Mailing Address - Street 2:
Mailing Address - City:LEMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60439-8433
Mailing Address - Country:US
Mailing Address - Phone:630-405-8753
Mailing Address - Fax:
Practice Address - Street 1:55510 INDIAN LAKE ROAD
Practice Address - Street 2:
Practice Address - City:DOWAGIAC
Practice Address - State:MI
Practice Address - Zip Code:49047
Practice Address - Country:US
Practice Address - Phone:630-405-8753
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI22066-202080N0001X
IN01037362A2080N0001X
MI43010341182080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IND87508Medicare UPIN