Provider Demographics
NPI:1205062692
Name:DONOVAN, CORY AMANDA (MD)
Entity type:Individual
Prefix:
First Name:CORY
Middle Name:AMANDA
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 1:3701 WILSHIRE BOULEVARD
Mailing Address - Street 2:SUITE 600
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-4041
Mailing Address - Country:US
Mailing Address - Phone:323-361-3550
Mailing Address - Fax:
Practice Address - Street 1:1040 NW 22ND AVE STE 560
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3097
Practice Address - Country:US
Practice Address - Phone:503-413-5525
Practice Address - Fax:503-413-5526
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-31
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD1812982086X0206X
WAMD60729370208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology