Provider Demographics
NPI:1295739019
Name:DONOVAN, TERRY ANN (DPM)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:ANN
Last Name:DONOVAN
Suffix:
Gender:F
Credentials:DPM
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 268
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-0268
Mailing Address - Country:US
Mailing Address - Phone:336-766-8400
Mailing Address - Fax:336-766-8486
Practice Address - Street 1:6341 COOK AVE
Practice Address - Street 2:STE A
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-9380
Practice Address - Country:US
Practice Address - Phone:336-766-8400
Practice Address - Fax:336-766-8486
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC203213E00000X, 213ES0131X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
561696265OtherCOMMERCIAL
NC8908053Medicaid
NC0346740001Medicare NSC
561696265OtherCOMMERCIAL
NCNC2383B699Medicare UPIN
NC6712460017Medicare NSC
T64102Medicare UPIN