Provider Demographics
NPI:1710082011
Name:DONNELLAN, KEVIN (MSPT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:DONNELLAN
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1510 SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:CARDIFF
Mailing Address - State:CA
Mailing Address - Zip Code:92007-2434
Mailing Address - Country:US
Mailing Address - Phone:631-807-5354
Mailing Address - Fax:
Practice Address - Street 1:7450 GIRARD AVE
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-5142
Practice Address - Country:US
Practice Address - Phone:858-454-9769
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024711225100000X
CA33148225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQP9791Medicare ID - Type Unspecified