Provider Demographics
NPI:1699729384
Name:MCDONNELL, WILLIAM M
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:M
Last Name:MCDONNELL
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 1:295 CHIPETA WAY
Mailing Address - Street 2:PEDS ADMIN
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-1220
Mailing Address - Country:US
Mailing Address - Phone:801-587-7450
Mailing Address - Fax:801-587-7455
Practice Address - Street 1:100 N MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84113-1103
Practice Address - Country:US
Practice Address - Phone:801-588-2233
Practice Address - Fax:801-588-2236
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR040345208000000X, 2080P0204X
UT6275131 1205208000000X
UT6275131 89052080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTH63914Medicare UPIN
COH63914Medicare UPIN