MEDICARE: DR. STEPHEN L DONALDSON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician	180090-1205	UT

General Provider Information

NPI Number	:	1578552634
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STEPHEN L DONALDSON MD

Provider Business Mailing Address
First Line	:	509 E 4190 N
Second Line	:
City	:	PROVO
State	:	UT
Zip	:	84604-5156
Country	:	US
Telephone Number	:	801-888-5234
Fax Number	:

Provider Business Practice Location Address
First Line	:	1055 N 500 W STE 201
Second Line	:
City	:	PROVO
State	:	UT
Zip	:	84604-3305
Country	:	US
Telephone Number	:	801-375-6565
Fax Number	:	801-373-9750

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/20/2005
Last Update Date	:	09/26/2019

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