Provider Demographics
NPI:1285650978
Name:DONOGHUE, BRIAN D (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:D
Last Name:DONOGHUE
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 1:2500 BLUE RIDGE RD STE 417
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-7516
Mailing Address - Country:US
Mailing Address - Phone:919-787-9097
Mailing Address - Fax:
Practice Address - Street 1:4420 LAKE BOONE TRL
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-7505
Practice Address - Country:US
Practice Address - Phone:919-784-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.087179207P00000X
KY42033207P00000X
NC2010-01730207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100041940Medicaid
OH2673683Medicaid
NC5916138Medicaid
OH2673683Medicaid
OH4191031Medicare PIN
KY00415012Medicare PIN
KY7100041940Medicaid
NC5916138Medicaid
NC2076971Medicare PIN