Provider Demographics
NPI:1962439703
Name:HARRELL, DONALD S (MD)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:S
Last Name:HARRELL
Suffix:
Gender:M
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:PO BOX 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:323-442-8541
Mailing Address - Fax:323-442-8755
Practice Address - Street 1:1500 SAN PABLO ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-5313
Practice Address - Country:US
Practice Address - Phone:323-442-8541
Practice Address - Fax:323-442-8755
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG513702085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G513700Medicaid
CA00G513700OtherBLUE SHIELD
CA00G513700G56OtherCAL-OPTIMA
CA300031906OtherRAIL ROAD
CA00G513700OtherBLUE SHIELD
CA00G513700Medicaid
CAWG51370EMedicare PIN
CAWG51370HMedicare PIN
CAWG51370IMedicare PIN
CAWG51370DMedicare PIN
CAE89036Medicare UPIN