Provider Demographics
NPI:1255323895
Name:DONNELLY, THOMAS J (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:J
Last Name:DONNELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 S MAIN ST
Mailing Address - Street 2:#2
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45409-2698
Mailing Address - Country:US
Mailing Address - Phone:937-461-5815
Mailing Address - Fax:937-461-2896
Practice Address - Street 1:1520 S MAIN ST
Practice Address - Street 2:#2
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-2698
Practice Address - Country:US
Practice Address - Phone:937-461-5815
Practice Address - Fax:937-461-2896
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35072508207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000012219OtherANTHEM BCBS
OH4800316OtherUNITED HEALTHCARE
OH2017669Medicaid
OHF51387Medicare UPIN
OH4800316OtherUNITED HEALTHCARE