Provider Demographics
NPI:1104843937
Name:PESAVENTO, DONALD (MD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:
Last Name:PESAVENTO
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 1:9301 CONNECTICUT DRIVE
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-7486
Mailing Address - Country:US
Mailing Address - Phone:219-756-2100
Mailing Address - Fax:
Practice Address - Street 1:9301 CONNECTICUT DRIVE
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-7486
Practice Address - Country:US
Practice Address - Phone:219-796-4117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01032265A208600000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM400048639Medicare PIN
IN704650Medicare PIN