Provider Demographics
NPI:1578552634
Name:DONALDSON, STEPHEN L (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:L
Last Name:DONALDSON
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 1:509 E 4190 N
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-5156
Mailing Address - Country:US
Mailing Address - Phone:801-888-5234
Mailing Address - Fax:
Practice Address - Street 1:1055 N 500 W STE 201
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3305
Practice Address - Country:US
Practice Address - Phone:801-375-6565
Practice Address - Fax:801-373-9750
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT180090-1205207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E92807Medicare UPIN
E92807Medicare UPIN