Provider Demographics
NPI:1235195207
Name:DONNELLY, BETH M (MD)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:M
Last Name:DONNELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:BETH
Other - Middle Name:M
Other - Last Name:MACDONALD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1 HOSPITAL ROAD
Mailing Address - Street 2:
Mailing Address - City:OAK BLUFFS
Mailing Address - State:MA
Mailing Address - Zip Code:02557-1477
Mailing Address - Country:US
Mailing Address - Phone:508-693-0410
Mailing Address - Fax:508-693-5971
Practice Address - Street 1:1 HOSPITAL ROAD
Practice Address - Street 2:
Practice Address - City:OAK BLUFFS
Practice Address - State:MA
Practice Address - Zip Code:02557-1477
Practice Address - Country:US
Practice Address - Phone:508-693-0410
Practice Address - Fax:508-693-5971
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2018-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA215522207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2000253Medicaid
H71269Medicare UPIN
MA2000253Medicaid