Provider Demographics
NPI:1780679209
Name:DONOVAN, KEVIN L (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:L
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 1:2165 HERSCHEL ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-3819
Mailing Address - Country:US
Mailing Address - Phone:904-387-4030
Mailing Address - Fax:904-381-9808
Practice Address - Street 1:1800 BARRS ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4704
Practice Address - Country:US
Practice Address - Phone:904-387-4030
Practice Address - Fax:904-381-9808
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME78056207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00843642AMedicaid
FL46914OtherBLUE CROSS BLUE SHIELD
D98385Medicare UPIN
FL46914OtherBLUE CROSS BLUE SHIELD