Provider Demographics
NPI:1750348934
Name:DONAHOE, C RONALD (M D)
Entity type:Individual
Prefix:
First Name:C
Middle Name:RONALD
Last Name:DONAHOE
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1704 BYRNEBRUK DR
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-9263
Mailing Address - Country:US
Mailing Address - Phone:217-355-3812
Mailing Address - Fax:
Practice Address - Street 1:1704 BYRNEBRUK DR
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-9263
Practice Address - Country:US
Practice Address - Phone:217-355-3812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-29
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-0792142085R0202X
TXE43002085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036079214Medicaid
D48233Medicare UPIN