Provider Demographics
NPI:1154394062
Name:DONNELLY, ANDREW DRISCOLL (MD)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:DRISCOLL
Last Name:DONNELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-4138
Mailing Address - Country:US
Mailing Address - Phone:918-299-8080
Mailing Address - Fax:918-298-2838
Practice Address - Street 1:619 E MAIN ST
Practice Address - Street 2:
Practice Address - City:JENKS
Practice Address - State:OK
Practice Address - Zip Code:74037-4138
Practice Address - Country:US
Practice Address - Phone:918-299-8080
Practice Address - Fax:918-298-2838
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK21227207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100254480CMedicaid
OK242401604Medicare ID - Type Unspecified
H40870Medicare UPIN