Provider Demographics
NPI:1316169709
Name:PAUL W. DONNELLY
Entity type:Organization
Organization Name:PAUL W. DONNELLY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:W
Authorized Official - Last Name:DONNELLY
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:360-352-3140
Mailing Address - Street 1:108 22ND AVE SW
Mailing Address - Street 2:SUITE 2
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98501-2871
Mailing Address - Country:US
Mailing Address - Phone:360-352-3140
Mailing Address - Fax:
Practice Address - Street 1:108 22ND AVE SW
Practice Address - Street 2:SUITE 2
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98501-2871
Practice Address - Country:US
Practice Address - Phone:360-352-3140
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADO00000478332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1750405320OtherPAUL DONNELLY NPI
WA0291220001Medicare NSC