Provider Demographics
NPI:1902802192
Name:DONNELLY, MARK E (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:E
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 1:1200 N BEAVER ST
Mailing Address - Street 2:PAYER CREDENTIALING
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3118
Mailing Address - Country:US
Mailing Address - Phone:928-773-2559
Mailing Address - Fax:928-213-6292
Practice Address - Street 1:1215 N BEAVER ST
Practice Address - Street 2:STE 202
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3126
Practice Address - Country:US
Practice Address - Phone:928-773-2200
Practice Address - Fax:928-773-2201
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ18917174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ286874Medicaid
AZP01112889OtherRAILROAD MEDICARE
AZB00109Medicare UPIN
AZP01112889OtherRAILROAD MEDICARE