Provider Demographics
NPI:1174631410
Name:YAMADA, DONOVAN LYLE (MD)
Entity Type:Individual
Prefix:
First Name:DONOVAN
Middle Name:LYLE
Last Name:YAMADA
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 1:2001 LAUREL AVE # N304
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37916-1810
Mailing Address - Country:US
Mailing Address - Phone:865-595-4100
Mailing Address - Fax:865-766-0133
Practice Address - Street 1:2001 LAUREL AVE # N304
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37916-1810
Practice Address - Country:US
Practice Address - Phone:865-595-4100
Practice Address - Fax:865-766-0133
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN417262085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3828091Medicaid
TN3828090Medicaid
TNP000379147OtherRR MCARE-CI
AL5905474Medicaid
TNP000365256OtherRR MCARE-ADR
TNP000379147OtherRR MCARE-CI
TNP000365256OtherRR MCARE-ADR
TN3828091Medicaid
TN3828090Medicaid