Provider Demographics
NPI:1760700918
Name:DONNELLY, ABIGAIL F (MD)
Entity Type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:F
Last Name:DONNELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9016
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:755 W CARMEL DR
Practice Address - Street 2:SUITE 101
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-5877
Practice Address - Country:US
Practice Address - Phone:317-846-2396
Practice Address - Fax:317-846-1699
Is Sole Proprietor?:No
Enumeration Date:2010-05-12
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01076565A207N00000X
AZ390200000X
CAA131222207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ710962Medicaid
AZZ91605Medicare PIN