Provider Demographics
NPI:1841925385
Name:MCDONALD, ROB IV
Entity type:Individual
Prefix:
First Name:ROB
Middle Name:
Last Name:MCDONALD
Suffix:IV
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 S EL DORADO ST STE 510
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95202-2804
Mailing Address - Country:US
Mailing Address - Phone:209-623-1411
Mailing Address - Fax:
Practice Address - Street 1:2423 W MARCH LN STE 200
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-8250
Practice Address - Country:US
Practice Address - Phone:209-623-1411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-19
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker