Provider Demographics
NPI:1417952250
Name:DONOVAN, MARK L (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:L
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 1:301 MED TECH PKWY
Mailing Address - Street 2:STE. 160
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2364
Mailing Address - Country:US
Mailing Address - Phone:423-794-5560
Mailing Address - Fax:423-794-1801
Practice Address - Street 1:301 MED TECH PKWY
Practice Address - Street 2:STE. 160
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-2364
Practice Address - Country:US
Practice Address - Phone:423-794-5560
Practice Address - Fax:423-794-1801
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2016-01-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN18834208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3042289Medicaid
TN103I370076Medicare PIN
TN3042289Medicaid