Provider Demographics
NPI:1811938509
Name:DONNELLY, SANDRA GAIL (MD)
Entity type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:GAIL
Last Name:DONNELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 SUMMITCREST
Mailing Address - Street 2:
Mailing Address - City:TRABUCO CANYON
Mailing Address - State:CA
Mailing Address - Zip Code:92679-3411
Mailing Address - Country:US
Mailing Address - Phone:949-858-9708
Mailing Address - Fax:
Practice Address - Street 1:9080 COLIMA RD
Practice Address - Street 2:
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90605-1600
Practice Address - Country:US
Practice Address - Phone:562-907-1565
Practice Address - Fax:562-907-1585
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG49068207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G490680Medicaid
CAE51150Medicare UPIN
CA00G490680Medicaid
CAWG49068Medicare ID - Type Unspecified
WG49068GMedicare PIN
CAWG49068EMedicare PIN