Provider Demographics
NPI:1164406500
Name:DONOVAN, JEREMIAH PAUL (MD)
Entity Type:Individual
Prefix:DR
First Name:JEREMIAH
Middle Name:PAUL
Last Name:DONOVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JEREMIAH
Other - Middle Name:P
Other - Last Name:DONOVAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:6451 N FEDERAL HWY STE 800
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-1409
Mailing Address - Country:US
Mailing Address - Phone:800-586-5022
Mailing Address - Fax:866-889-7835
Practice Address - Street 1:1500 DUARTE RD
Practice Address - Street 2:
Practice Address - City:DUARTE
Practice Address - State:CA
Practice Address - Zip Code:91010-3012
Practice Address - Country:US
Practice Address - Phone:626-256-4673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60692631207RG0100X
CAG150240207RG0100X
FLME95167207RG0100X
ND13130207RG0100X
MEMD24904207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND15201Medicaid
FL37233OtherBCBS
NDN715106Medicare PIN
37233Medicare ID - Type Unspecified
FL37233OtherBCBS
FL37233WMedicare PIN