Provider Demographics
NPI: | 1467412023 |
---|---|
Name: | DOVGAN, DANIEL J (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | DANIEL |
Middle Name: | J |
Last Name: | DOVGAN |
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: | PO BOX 1445 |
Mailing Address - Street 2: | |
Mailing Address - City: | INDIANAPOLIS |
Mailing Address - State: | IN |
Mailing Address - Zip Code: | 46206-1445 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 866-388-2916 |
Mailing Address - Fax: | 855-388-4124 |
Practice Address - Street 1: | 907 E LAMAR ALEXANDER PKWY |
Practice Address - Street 2: | |
Practice Address - City: | MARYVILLE |
Practice Address - State: | TN |
Practice Address - Zip Code: | 37804-5015 |
Practice Address - Country: | US |
Practice Address - Phone: | 865-977-5567 |
Practice Address - Fax: | 865-980-4962 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-03-27 |
Last Update Date: | 2017-02-02 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
TN | 27473 | 2085R0202X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2085R0202X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
KY | 64923386 | Medicaid | |
TN | 4023058 | Other | BC/BS OF TN |
TN | 300125493 | Other | RR MCARE |
TN | 3097904 | Medicaid | |
TN | G01422 | Medicare UPIN | |
TN | 300125493 | Other | RR MCARE |
TN | 300125493 | Medicare PIN |