Provider Demographics
NPI:1760481154
Name:DONATHAN, MARK ALLEN (MPT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ALLEN
Last Name:DONATHAN
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10980 NORCOM RD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19154-2302
Mailing Address - Country:US
Mailing Address - Phone:215-872-3595
Mailing Address - Fax:
Practice Address - Street 1:10980 NORCOM RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19154-2302
Practice Address - Country:US
Practice Address - Phone:215-872-3595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-18
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT012924L174400000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA11351751OtherCAQH
PA1333102OtherHIGHMARK
PA2025970000OtherAMERIHEALTH
PA2025970000OtherIBC
PA2025970000OtherIBC