Provider Demographics
NPI:1457971103
Name:DONOVAN, ALEXANDER GEORGE
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:GEORGE
Last Name:DONOVAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ALEX
Other - Middle Name:GEORGE
Other - Last Name:DONOVAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:726 S 159TH AVE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68118-2139
Mailing Address - Country:US
Mailing Address - Phone:402-350-3653
Mailing Address - Fax:
Practice Address - Street 1:15340 WEIR ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137-5005
Practice Address - Country:US
Practice Address - Phone:402-932-9222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-23
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10029T152W00000X
NE1570152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist