Provider Demographics
NPI:1598741787
Name:DONOVAN, BRIAN P (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:P
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 1:119 BOONE RIDGE DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-4998
Mailing Address - Country:US
Mailing Address - Phone:423-282-1480
Mailing Address - Fax:423-928-1353
Practice Address - Street 1:119 BOONE RIDGE DR
Practice Address - Street 2:SUITE 201
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37615-4998
Practice Address - Country:US
Practice Address - Phone:423-282-1480
Practice Address - Fax:423-928-1353
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN19590208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN201217521OtherPHP
TN4121972OtherBCBST
VA010344638Medicaid
TNTN0111OtherJOHN DEERE HEALTHCARE
TN3046236Medicaid
TN201217521OtherPHP
TNTN0111OtherJOHN DEERE HEALTHCARE