Provider Demographics
NPI:1164435301
Name:DONNELLY, WALTER GERARD JR (MD)
Entity Type:Individual
Prefix:MR
First Name:WALTER
Middle Name:GERARD
Last Name:DONNELLY
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 679
Mailing Address - Street 2:
Mailing Address - City:SHARON
Mailing Address - State:CT
Mailing Address - Zip Code:06069-0679
Mailing Address - Country:US
Mailing Address - Phone:860-364-5646
Mailing Address - Fax:860-364-5265
Practice Address - Street 1:29 HOSPITAL HILL RD
Practice Address - Street 2:SUITE #1100
Practice Address - City:SHARON
Practice Address - State:CT
Practice Address - Zip Code:06069
Practice Address - Country:US
Practice Address - Phone:860-364-5646
Practice Address - Fax:860-364-5265
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CT018261207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
010018261CT01OtherANTHEM BLUE CROSS BLUE SH
040220OtherHEALTH NET
NY00508470Medicaid
040220OtherHEALTH NET