Provider Demographics
NPI:1326090705
Name:DONAHUE, MARY JO (MD)
Entity Type:Individual
Prefix:
First Name:MARY JO
Middle Name:
Last Name:DONAHUE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20911 EARL ST
Mailing Address - Street 2:STE 400
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-4352
Mailing Address - Country:US
Mailing Address - Phone:310-371-1010
Mailing Address - Fax:
Practice Address - Street 1:20911 EARL ST
Practice Address - Street 2:STE 400
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-4352
Practice Address - Country:US
Practice Address - Phone:310-371-1010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA43741207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA43741QMedicare ID - Type UnspecifiedMEDICARE PPIN
CAWA43741IMedicare ID - Type UnspecifiedMEDICARE PPIN
E83596Medicare UPIN