Provider Demographics
NPI:1336130095
Name:DONOVAN, MICHELE ANN (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHELE
Middle Name:ANN
Last Name:DONOVAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2015 SAM RITTENBERG BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-4601
Mailing Address - Country:US
Mailing Address - Phone:843-763-2247
Mailing Address - Fax:
Practice Address - Street 1:2015 SAM RITTENBERG BLVD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-4601
Practice Address - Country:US
Practice Address - Phone:843-763-2247
Practice Address - Fax:843-763-1068
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1308152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD13082Medicaid
SCD13082Medicaid
SC7845Medicare PIN