Provider Demographics
NPI:1871737247
Name:MCDONALD, TEDDY DESHA
Entity type:Individual
Prefix:MR
First Name:TEDDY
Middle Name:DESHA
Last Name:MCDONALD
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:TED
Other - Middle Name:DESHA
Other - Last Name:MCDONALD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6088 MONTEREY HWY APT 302
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95138-1758
Mailing Address - Country:US
Mailing Address - Phone:209-509-6842
Mailing Address - Fax:
Practice Address - Street 1:2001 THE ALAMEDA
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95126-1136
Practice Address - Country:US
Practice Address - Phone:408-261-7777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-28
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator