Provider Demographics
NPI:1184393506
Name:DONNELLY, BENJAMIN CORNELIUS (SOIDC)
Entity type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:CORNELIUS
Last Name:DONNELLY
Suffix:
Gender:M
Credentials:SOIDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2D RECONNAISSANCE BATTALION
Mailing Address - Street 2:PSC BOX 20138
Mailing Address - City:APO
Mailing Address - State:AA
Mailing Address - Zip Code:28542-0138
Mailing Address - Country:US
Mailing Address - Phone:910-440-7703
Mailing Address - Fax:
Practice Address - Street 1:2D MARDIV
Practice Address - Street 2:2D RECONNAISSANCE BN
Practice Address - City:APO
Practice Address - State:AA
Practice Address - Zip Code:28542-0138
Practice Address - Country:US
Practice Address - Phone:910-440-7703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-09
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman