Provider Demographics
NPI:1770652828
Name:FENNELL, DONALD WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:WAYNE
Last Name:FENNELL
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:716 LIGHTHOUSE AVE
Mailing Address - Street 2:SUITE D-1
Mailing Address - City:PACIFIC GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:93950-2565
Mailing Address - Country:US
Mailing Address - Phone:831-655-3392
Mailing Address - Fax:831-647-7940
Practice Address - Street 1:716 LIGHTHOUSE AVE
Practice Address - Street 2:SUITE D-1
Practice Address - City:PACIFIC GROVE
Practice Address - State:CA
Practice Address - Zip Code:93950-2565
Practice Address - Country:US
Practice Address - Phone:831-655-3392
Practice Address - Fax:831-647-7940
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG554222084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA72651Medicare UPIN