Provider Demographics
NPI:1417990003
Name:WONDERLY, DONALD E (MD)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:E
Last Name:WONDERLY
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:PO BOX 568
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:OR
Mailing Address - Zip Code:97495-0568
Mailing Address - Country:US
Mailing Address - Phone:541-677-4427
Mailing Address - Fax:541-677-6522
Practice Address - Street 1:2460 NW STEWART PKWY
Practice Address - Street 2:SUITE 240
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-1516
Practice Address - Country:US
Practice Address - Phone:541-677-4427
Practice Address - Fax:541-677-6522
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD22082207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR134096Medicaid
H03874Medicare UPIN
ORR113594Medicare PIN