Provider Demographics
NPI:1861449274
Name:DONNELLY, HEIDI B (MD)
Entity Type:Individual
Prefix:DR
First Name:HEIDI
Middle Name:B
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 1:830 OAKWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:OAKWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45419-2937
Mailing Address - Country:US
Mailing Address - Phone:937-643-9213
Mailing Address - Fax:
Practice Address - Street 1:3025 GOVERNORS PLACE BLVD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-1330
Practice Address - Country:US
Practice Address - Phone:937-293-5567
Practice Address - Fax:937-293-5568
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-30
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35073167207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHG14948Medicare UPIN
OHHE9327881Medicare ID - Type Unspecified