Provider Demographics
NPI:1124020557
Name:DONNELLY, KEVIN J (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:J
Last Name:DONNELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1330 S FORT HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33756-3313
Mailing Address - Country:US
Mailing Address - Phone:727-791-1368
Mailing Address - Fax:727-216-0704
Practice Address - Street 1:120 MEDICAL BLVD STE 105
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34609-0221
Practice Address - Country:US
Practice Address - Phone:727-441-3588
Practice Address - Fax:727-216-0704
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME68587207Y00000X
FLME0068587174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG05921Medicare UPIN
FL26143ZMedicare ID - Type Unspecified