Provider Demographics
NPI:1386672368
Name:DONNELLY, PAUL THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:THOMAS
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 1:571 SAINT JOSEPHS BLVD FL 2
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-3230
Mailing Address - Country:US
Mailing Address - Phone:607-271-2050
Mailing Address - Fax:
Practice Address - Street 1:104 S PORTER ST
Practice Address - Street 2:
Practice Address - City:WATKINS GLEN
Practice Address - State:NY
Practice Address - Zip Code:14891-1622
Practice Address - Country:US
Practice Address - Phone:607-535-7873
Practice Address - Fax:607-535-7469
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY162852-1207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
080194958OtherRR MEDICARE
NY01037172Medicaid
080194958OtherRR MEDICARE
NYDD4894Medicare ID - Type Unspecified