Provider Demographics
NPI:1003853870
Name:DONNELLY, DAVID M (RPT)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:M
Last Name:DONNELLY
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:465 WOLCOTT RD
Mailing Address - Street 2:
Mailing Address - City:WOLCOTT
Mailing Address - State:CT
Mailing Address - Zip Code:06716-2613
Mailing Address - Country:US
Mailing Address - Phone:203-879-0107
Mailing Address - Fax:203-879-0206
Practice Address - Street 1:465 WOLCOTT RD
Practice Address - Street 2:
Practice Address - City:WOLCOTT
Practice Address - State:CT
Practice Address - Zip Code:06716-2613
Practice Address - Country:US
Practice Address - Phone:203-879-0107
Practice Address - Fax:203-879-0206
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT006743225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004212619Medicaid
CT650001124Medicare PIN