Provider Demographics
NPI:1023102456
Name:DONNELLY, JON PATRICK (MD)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:PATRICK
Last Name:DONNELLY
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 1:5 PEARL STREET
Mailing Address - Street 2:
Mailing Address - City:CAPE ELIZABETH
Mailing Address - State:ME
Mailing Address - Zip Code:04107
Mailing Address - Country:US
Mailing Address - Phone:207-799-6096
Mailing Address - Fax:
Practice Address - Street 1:71 US ROUTE 1
Practice Address - Street 2:SUITE C
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-7173
Practice Address - Country:US
Practice Address - Phone:207-883-5532
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD143242080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME315420099Medicaid
G28759Medicare UPIN
DOMM6376Medicare ID - Type Unspecified