Healthcare Provider Details

I. General information

NPI: 1538351911
Provider Name (Legal Business Name): MICHAEL DONAHUE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2007
Last Update Date: 08/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 DUARTE RD
DUARTE CA
91010-3012
US

IV. Provider business mailing address

PO BOX 512185
LOS ANGELES CA
90051-0185
US

V. Phone/Fax

Practice location:
  • Phone: 303-494-0200
  • Fax:
Mailing address:
  • Phone: 626-775-3514
  • Fax: 626-218-5310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG58823
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: