Provider Demographics
NPI:1417229493
Name:KENNETH DONOVAN DPM LLC
Entity Type:Organization
Organization Name:KENNETH DONOVAN DPM LLC
Other - Org Name:ADVANCED CARE FOOT AND ANKLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:DONOVAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:908-605-0799
Mailing Address - Street 1:9 MOUNT BETHEL RD
Mailing Address - Street 2:SUITE 209
Mailing Address - City:WARREN
Mailing Address - State:NJ
Mailing Address - Zip Code:07059-5603
Mailing Address - Country:US
Mailing Address - Phone:908-605-0799
Mailing Address - Fax:908-450-1558
Practice Address - Street 1:9 MOUNT BETHEL RD
Practice Address - Street 2:SUITE 209
Practice Address - City:WARREN
Practice Address - State:NJ
Practice Address - Zip Code:07059-5603
Practice Address - Country:US
Practice Address - Phone:908-605-0799
Practice Address - Fax:908-450-1558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-06
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00302600213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ187600P7BMedicare PIN