Provider Demographics
NPI:1053315457
Name:DONNELLY, EDWIN H (MD)
Entity type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:H
Last Name:DONNELLY
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:975 JOHNSON FERRY RD NE
Mailing Address - Street 2:SUITE 370
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1619
Mailing Address - Country:US
Mailing Address - Phone:404-250-1242
Mailing Address - Fax:404-250-1232
Practice Address - Street 1:975 JOHNSON FERRY RD NE
Practice Address - Street 2:SUITE 370
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1619
Practice Address - Country:US
Practice Address - Phone:404-250-1242
Practice Address - Fax:404-250-1232
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-13
Last Update Date:2017-10-04
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Provider Licenses
StateLicense IDTaxonomies
GA019156207W00000X, 207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA581425151OtherTAX ID
GA00154206BMedicaid
GA00154206BMedicaid