Provider Demographics
NPI:1013972744
Name:DONNELLY, DIANE K (MD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:K
Last Name:DONNELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:CAROL
Other - Last Name:KLAUSER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3985 COLUMBIA AVE STE 8
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:PA
Mailing Address - Zip Code:17512-9003
Mailing Address - Country:US
Mailing Address - Phone:717-285-3144
Mailing Address - Fax:717-285-3529
Practice Address - Street 1:3985 COLUMBIA AVE STE 8
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:PA
Practice Address - Zip Code:17512-9003
Practice Address - Country:US
Practice Address - Phone:717-285-3144
Practice Address - Fax:717-285-3529
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2020-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD453617207Q00000X
VA0101235700207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA793859082AMedicaid
GA08CRRTHOtherMEDICARE
VA013817F32Medicare ID - Type Unspecified
GAI03146Medicare UPIN