Healthcare Provider Details

I. General information

NPI: 1124020557
Provider Name (Legal Business Name): KEVIN J DONNELLY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2005
Last Update Date: 04/29/2021
Certification Date: 04/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 MEDICAL BLVD STE 105
SPRING HILL FL
34609-0221
US

IV. Provider business mailing address

1330 S FORT HARRISON AVE
CLEARWATER FL
33756-3313
US

V. Phone/Fax

Practice location:
  • Phone: 727-441-3588
  • Fax: 727-216-0704
Mailing address:
  • Phone: 727-791-1368
  • Fax: 727-216-0704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberME68587
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME0068587
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: