Provider Demographics
NPI:1255361291
Name:DONNELLY, CYNTHIA O (OD)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:O
Last Name:DONNELLY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1016 KIRKPATRICK ROAD
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27215-9714
Mailing Address - Country:US
Mailing Address - Phone:336-228-0254
Mailing Address - Fax:336-584-0101
Practice Address - Street 1:1016 KIRKPATRICK ROAD
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-9714
Practice Address - Country:US
Practice Address - Phone:336-228-0254
Practice Address - Fax:336-584-0101
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1184152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8909264Medicaid
NC8909264Medicaid
NC0366180001Medicare NSC
NC0366180016Medicare NSC
NC246570CMedicare PIN