Provider Demographics
NPI:1578866018
Name:MCDONALD, ROBERT VADEN (MT)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:VADEN
Last Name:MCDONALD
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2520 PEACHTREE RD NW
Mailing Address - Street 2:APT 113
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-3691
Mailing Address - Country:US
Mailing Address - Phone:404-952-7389
Mailing Address - Fax:
Practice Address - Street 1:2520 PEACHTREE RD NW
Practice Address - Street 2:APT 113
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30305-3691
Practice Address - Country:US
Practice Address - Phone:404-952-7389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-06
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT005670225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist