Provider Demographics
NPI:1568736775
Name:DONOVAN, MARK THOMAS
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:THOMAS
Last Name:DONOVAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:666 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02127-1502
Mailing Address - Country:US
Mailing Address - Phone:617-239-4354
Mailing Address - Fax:617-268-2805
Practice Address - Street 1:666 E BROADWAY
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02127-1502
Practice Address - Country:US
Practice Address - Phone:617-239-4354
Practice Address - Fax:617-268-2805
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-06
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4282156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA35531OtherDAVIS
MA03149OtherSPECTRA
MAA08896OtherEYEMED