Provider Demographics
NPI:1366805517
Name:DONNELLY, KEVIN (M D)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:DONNELLY
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 ALTAIR PKWY
Mailing Address - Street 2:STE 210
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43082-4647
Mailing Address - Country:US
Mailing Address - Phone:614-898-7546
Mailing Address - Fax:614-794-4294
Practice Address - Street 1:430 ALTAIR PKWY
Practice Address - Street 2:STE 210
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43082-4647
Practice Address - Country:US
Practice Address - Phone:614-898-7546
Practice Address - Fax:614-794-4294
Is Sole Proprietor?:No
Enumeration Date:2016-04-04
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57.028833207R00000X
390200000X
NMRS2020-0028390200000X
OH35139165207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000001380472OtherANTHEM