Provider Demographics
NPI:1871587782
Name:DONATELLE, LAWRENCE R (MD)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:R
Last Name:DONATELLE
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 1:878 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-1461
Mailing Address - Country:US
Mailing Address - Phone:920-727-5982
Mailing Address - Fax:
Practice Address - Street 1:878 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952-1461
Practice Address - Country:US
Practice Address - Phone:920-727-5982
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI25239207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30647300Medicaid
WI001545300Medicare PIN
B52476Medicare UPIN
WI30647300Medicaid