Provider Demographics
NPI:1699724096
Name:MCDONALD, MALCOLM DWAIN (MD)
Entity type:Individual
Prefix:
First Name:MALCOLM
Middle Name:DWAIN
Last Name:MCDONALD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:M.
Other - Middle Name:DWAIN
Other - Last Name:MCDONALD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:500 GRAPEVINE HWY
Mailing Address - Street 2:STE 106
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76054-2707
Mailing Address - Country:US
Mailing Address - Phone:817-514-6271
Mailing Address - Fax:817-514-6278
Practice Address - Street 1:500 GRAPEVINE HWY
Practice Address - Street 2:STE 106
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76054-2707
Practice Address - Country:US
Practice Address - Phone:817-514-6271
Practice Address - Fax:817-514-6278
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXC9069207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXC-19132Medicare UPIN