Provider Demographics
NPI:1063485217
Name:SHIVELY, DONOVAN PAUL (MD)
Entity Type:Individual
Prefix:
First Name:DONOVAN
Middle Name:PAUL
Last Name:SHIVELY
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 1:4397 EDINBURG CT
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94534
Mailing Address - Country:US
Mailing Address - Phone:707-864-2311
Mailing Address - Fax:707-864-2317
Practice Address - Street 1:4397 EDINBURG CT
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94534
Practice Address - Country:US
Practice Address - Phone:707-864-2311
Practice Address - Fax:707-864-2317
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-08
Last Update Date:2009-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG21888207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G218880Medicaid
A41413Medicare UPIN
CA00G218880Medicaid