Provider Demographics
NPI:1982667903
Name:DONATELLI, TIMOTHY JOHN (DPM)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:JOHN
Last Name:DONATELLI
Suffix:
Gender:M
Credentials:DPM
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 365
Mailing Address - Street 2:
Mailing Address - City:PROSPERITY
Mailing Address - State:WV
Mailing Address - Zip Code:25909-0365
Mailing Address - Country:US
Mailing Address - Phone:304-228-8888
Mailing Address - Fax:
Practice Address - Street 1:401 ROGERS ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-3636
Practice Address - Country:US
Practice Address - Phone:304-487-9442
Practice Address - Fax:304-431-3558
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2009-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV 00363213E00000X
VA0103300831213E00000X
OH36003209D213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV300175239OtherWV WORKERS' COMPENSATION
WV2101008000Medicaid
300175239OtherUMWA
P00220975OtherRAILROAD MEDICARE
5467800001OtherMEDICARE DME
VA010201641Medicaid
VA010201641Medicaid
WVDO0863433Medicare PIN