Provider Demographics
NPI:1073564175
Name:DONVITO, MARK T (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:T
Last Name:DONVITO
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 1:405 W JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-1462
Mailing Address - Country:US
Mailing Address - Phone:800-701-3381
Mailing Address - Fax:
Practice Address - Street 1:2 S HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MURPHYSBORO
Practice Address - State:IL
Practice Address - Zip Code:62966-3333
Practice Address - Country:US
Practice Address - Phone:618-684-3156
Practice Address - Fax:618-529-0524
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-077356207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036077356-4Medicaid
KY1073564175Medicaid
KY1073564175Medicaid
IL$$$$$$$$$-3Medicaid
ILIL1943010Medicare PIN
IL036077356-4Medicaid
IL214881055Medicare PIN
P00317053Medicare PIN
213567Medicare PIN
K27646Medicare PIN