Healthcare Provider Details

I. General information

NPI: 1699338020
Provider Name (Legal Business Name): STEPHEN DONNELLY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2019
Last Update Date: 07/11/2026
Certification Date: 07/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10800 MAGNOLIA AVE
RIVERSIDE CA
92505-3043
US

IV. Provider business mailing address

10800 MAGNOLIA AVE
RIVERSIDE CA
92505-3043
US

V. Phone/Fax

Practice location:
  • Phone: 866-984-7483
  • Fax:
Mailing address:
  • Phone: 909-558-7674
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number20A20701
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: