Provider Demographics
NPI:1407850852
Name:DONOVAN, JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:DONOVAN
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 1:3099 RIVER RD S
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-9754
Mailing Address - Country:US
Mailing Address - Phone:503-581-1567
Mailing Address - Fax:503-399-1229
Practice Address - Street 1:3099 RIVER RD S
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-9754
Practice Address - Country:US
Practice Address - Phone:503-581-1567
Practice Address - Fax:503-399-1229
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2011-10-31
Deactivation Date:2006-03-24
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
ORBD1452399207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR044987Medicaid
OR0000WFBRWBMedicare ID - Type UnspecifiedMEDICARE
ORF31483Medicare UPIN