Provider Demographics
NPI:1427084425
Name:DONNELLY, BETH (MD)
Entity type:Individual
Prefix:
First Name:BETH
Middle Name:
Last Name:DONNELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 COUNTY RD 120
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-4665
Mailing Address - Country:US
Mailing Address - Phone:320-202-8949
Mailing Address - Fax:320-202-0756
Practice Address - Street 1:251 COUNTY RD 120
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-4665
Practice Address - Country:US
Practice Address - Phone:320-202-8949
Practice Address - Fax:320-202-0756
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN39478207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN696335800Medicaid
MNG46453Medicare UPIN
MN696335800Medicaid