Provider Demographics
NPI:1083125207
Name:DONATH, MICHAEL ALAN
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ALAN
Last Name:DONATH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 ROSE AVE
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-2767
Mailing Address - Country:US
Mailing Address - Phone:310-392-8636
Mailing Address - Fax:310-943-3521
Practice Address - Street 1:604 ROSE AVE
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291-2767
Practice Address - Country:US
Practice Address - Phone:310-392-8636
Practice Address - Fax:310-943-3521
Is Sole Proprietor?:No
Enumeration Date:2017-10-15
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPTL6442084P0800X
CAA1776612084P0015X, 2084P0800X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Yes2084P0015XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychosomatic Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA390200000XOther39 STUDENT,HEALTH CARE
CAA177661Medicaid