Provider Demographics
NPI:1245272947
Name:SEGARRA, DONNA LOUISE (DO)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:LOUISE
Last Name:SEGARRA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 OCEANGATE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-4317
Mailing Address - Country:US
Mailing Address - Phone:562-499-6191
Mailing Address - Fax:562-499-6171
Practice Address - Street 1:7317 CENTRAL AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-2015
Practice Address - Country:US
Practice Address - Phone:505-200-3320
Practice Address - Fax:877-860-2279
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-10
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB02875300207Q00000X
CA20A4585207Q00000X
CO20827207Q00000X
NMA567-71207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM23200863Medicaid
NMP01422153/DV3487OtherRAILROAD MEDICARE-ALBUQUERQUE
NJ1369504Medicaid
NM23200863Medicaid
NMNMA102856Medicare PIN
NJ1369504Medicaid