Provider Demographics
NPI:1669496147
Name:DONOVAN, MARTHA MANTILLA (MD)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:MANTILLA
Last Name:DONOVAN
Suffix:
Gender:F
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 60790
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91116-6790
Mailing Address - Country:US
Mailing Address - Phone:626-795-6596
Mailing Address - Fax:626-795-8247
Practice Address - Street 1:2975 SYCAMORE DR
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-1201
Practice Address - Country:US
Practice Address - Phone:805-955-6900
Practice Address - Fax:805-955-6063
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA53911207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A539112Medicaid
CA00A539110OtherBLUE SHIELD
CAA53911BMedicare ID - Type Unspecified
G53741Medicare UPIN