Provider Demographics
NPI:1295027688
Name:DONOVAN, JODIE L (MD)
Entity Type:Individual
Prefix:DR
First Name:JODIE
Middle Name:L
Last Name:DONOVAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JODIE
Other - Middle Name:L
Other - Last Name:NEWMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-2222
Mailing Address - Fax:
Practice Address - Street 1:300 E JEFFERSON ST
Practice Address - Street 2:SUITE 300
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6246
Practice Address - Country:US
Practice Address - Phone:208-381-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-04
Last Update Date:2015-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM 12673207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine