Provider Demographics
NPI:1659420875
Name:DONNELL, MALCOLM THOMAS
Entity Type:Individual
Prefix:
First Name:MALCOLM
Middle Name:THOMAS
Last Name:DONNELL
Suffix:
Gender:M
Credentials:
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 650865
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0865
Mailing Address - Country:US
Mailing Address - Phone:972-233-1999
Mailing Address - Fax:972-233-3666
Practice Address - Street 1:1500 CITYWEST BLVD
Practice Address - Street 2:STE. 300
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77042-2300
Practice Address - Country:US
Practice Address - Phone:713-620-4000
Practice Address - Fax:713-458-4229
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF9373207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX128170102Medicaid
TX050041740OtherRAILROAD MEDICARE
TX8AW302OtherBLUE CROSS BLUE SHIELD ID
TX128170106Medicaid
TX128170107Medicaid
LA1975974Medicaid
84Y541OtherTX-BLUE SHIELD
84Y541OtherTX-BLUE SHIELD
TX128170107Medicaid
LA1975974Medicaid
8K4739Medicare PIN