Provider Demographics
NPI:1689869836
Name:DAVID R DONALDSON M.D., PLLC
Entity Type:Organization
Organization Name:DAVID R DONALDSON M.D., PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBBY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILCOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-232-2146
Mailing Address - Street 1:333 N 18TH AVE
Mailing Address - Street 2:ST#B3
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-3358
Mailing Address - Country:US
Mailing Address - Phone:208-232-2146
Mailing Address - Fax:208-232-2770
Practice Address - Street 1:333 N 18TH AVE
Practice Address - Street 2:ST#B3
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201
Practice Address - Country:US
Practice Address - Phone:208-232-2146
Practice Address - Fax:208-232-2770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-11
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM9470261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty