Provider Demographics
NPI:1992745160
Name:MACDONELL, RICHARD A (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
Last Name:MACDONELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:695 NW YORK DR STE 100
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-9702
Mailing Address - Country:US
Mailing Address - Phone:541-322-6869
Mailing Address - Fax:541-639-3655
Practice Address - Street 1:695 NW YORK DR STE 100
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-9702
Practice Address - Country:US
Practice Address - Phone:541-322-6869
Practice Address - Fax:541-639-3655
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD22659207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR287696Medicaid
G84107Medicare UPIN
110186Medicare ID - Type Unspecified