Individual
MARK E DONNELLY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1215 N BEAVER ST, STE 202, FLAGSTAFF, AZ 86001-3126
(928) 773-2200
(928) 773-2201
Mailing address
1200 N BEAVER ST, PAYER CREDENTIALING, FLAGSTAFF, AZ 86001-3118
(928) 773-2559
(928) 213-6292
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
18917
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
286874
—
AZ
01
—
P01112889
RAILROAD MEDICARE
AZ
Enumeration date
06/22/2005
Last updated
03/14/2017
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