Provider Demographics
NPI:1689660490
Name:DONOVAN, WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
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 1:101 N PLAINS INDUSTRIAL RD
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-2360
Mailing Address - Country:US
Mailing Address - Phone:203-949-2700
Mailing Address - Fax:203-949-2712
Practice Address - Street 1:326 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-2740
Practice Address - Country:US
Practice Address - Phone:860-823-6303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT353552085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1353557Medicaid
G29094Medicare UPIN
CT300001900Medicare ID - Type Unspecified