Provider Demographics
NPI:1083685499
Name:DONOVAN, MARY C (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:C
Last Name:DONOVAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:C
Other - Last Name:WIESNEWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:20611 WATERTOWN RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-1871
Mailing Address - Country:US
Mailing Address - Phone:262-798-1810
Mailing Address - Fax:262-798-2614
Practice Address - Street 1:20611 WATERTOWN RD
Practice Address - Street 2:SUITE C
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-1871
Practice Address - Country:US
Practice Address - Phone:262-798-1810
Practice Address - Fax:262-798-2614
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI27603208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31393600Medicaid
F21869Medicare UPIN