Healthcare Provider Details

I. General information

NPI: 1770572067
Provider Name (Legal Business Name): MICHAEL PHILIP DONAHOE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2005
Last Update Date: 09/19/2023
Certification Date: 03/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12990 MANCHESTER RD STE 201
DES PERES MO
63131-1860
US

IV. Provider business mailing address

12990 MANCHESTER RD STE 201
DES PERES MO
63131-1860
US

V. Phone/Fax

Practice location:
  • Phone: 314-909-0633
  • Fax: 314-909-0391
Mailing address:
  • Phone: 314-909-0633
  • Fax: 314-909-0391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number102870
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: