Provider Demographics
NPI:1730142407
Name:DONNELLY, WALTER EDMUND (MD)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:EDMUND
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:P.O. BOX 706152
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45270-6152
Mailing Address - Country:US
Mailing Address - Phone:513-619-5014
Mailing Address - Fax:513-619-8713
Practice Address - Street 1:6331 GLENWAY AVENUE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45211
Practice Address - Country:US
Practice Address - Phone:513-389-1400
Practice Address - Fax:513-347-2119
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35050668207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0594987Medicaid
OHDO0577015Medicare ID - Type Unspecified
OHC03017Medicare UPIN