Provider Demographics
NPI:1588644041
Name:DONOVAN, BYRON LEE (MD)
Entity Type:Individual
Prefix:
First Name:BYRON
Middle Name:LEE
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:PO BOX 687
Mailing Address - Street 2:
Mailing Address - City:HYDETOWN
Mailing Address - State:PA
Mailing Address - Zip Code:16328-0687
Mailing Address - Country:US
Mailing Address - Phone:814-827-4185
Mailing Address - Fax:814-827-4185
Practice Address - Street 1:406 W OAK ST
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:PA
Practice Address - Zip Code:16354-1404
Practice Address - Country:US
Practice Address - Phone:814-827-1851
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD039449L207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010189590002Medicaid
PA464315Medicare ID - Type Unspecified
PA0010189590002Medicaid