Provider Demographics
NPI:1588804132
Name:DONOVAN, KENNETH JAMES (DPM)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:JAMES
Last Name:DONOVAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 MOUNT BETHEL RD
Mailing Address - Street 2:SUITE 9
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 9
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
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-23
Last Update Date:2024-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00302600213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0231622Medicaid