Provider Demographics
NPI:1700820784
Name:DONNELLY, MARK W (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:W
Last Name:DONNELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:525 N SANTIAM HWY
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OR
Mailing Address - Zip Code:97355-4363
Mailing Address - Country:US
Mailing Address - Phone:541-451-7115
Mailing Address - Fax:541-451-7095
Practice Address - Street 1:525 N SANTIAM HWY
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OR
Practice Address - Zip Code:97355-4363
Practice Address - Country:US
Practice Address - Phone:541-451-7115
Practice Address - Fax:541-451-7095
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2011-12-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
ORMD23406207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORH65124Medicare UPIN