Basic Information
| Provider Information | |||||||||
| NPI: | 1720189632 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DONALDSON | ||||||||
| FirstName: | LAURIE | ||||||||
| MiddleName: | DIANE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3621 S STATE ST | ||||||||
| Address2: | 700 KMS PLACE | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349362047 | ||||||||
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| Practice Location | |||||||||
| Address1: | 24 FRANK LLOYD WRIGHT DR | ||||||||
| Address2: | LOBBY A | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481059484 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349307400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2006 | ||||||||
| LastUpdateDate: | 10/22/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 4301086674 | MI | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080S0010X | 4301086674 | MI | Y | Allopathic & Osteopathic Physicians | Pediatrics | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4828620 | 05 | MI | MEDICAID |