Provider Demographics
NPI:1609189042
Name:MCDONNELL DERMATOLOGY LLC
Entity Type:Organization
Organization Name:MCDONNELL DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JONELLE
Authorized Official - Middle Name:K
Authorized Official - Last Name:MCDONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-205-3376
Mailing Address - Street 1:25097 OLYMPIA AVE
Mailing Address - Street 2:STE 204
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33950-3903
Mailing Address - Country:US
Mailing Address - Phone:941-205-3376
Mailing Address - Fax:
Practice Address - Street 1:25097 OLYMPIA AVE
Practice Address - Street 2:STE 204
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33950-3903
Practice Address - Country:US
Practice Address - Phone:941-205-6676
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-14
Last Update Date:2010-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME104122207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME104122OtherMEDICAL LICENSE NUMBER