Provider Demographics
NPI:1811966898
Name:BLAND, DONOVAN C (MD)
Entity type:Individual
Prefix:
First Name:DONOVAN
Middle Name:C
Last Name:BLAND
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 1:6320 N LA CHOLLA BLVD
Mailing Address - Street 2:SUITE 310
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85741-3552
Mailing Address - Country:US
Mailing Address - Phone:520-219-9125
Mailing Address - Fax:520-219-9130
Practice Address - Street 1:6320 N LA CHOLLA BLVD
Practice Address - Street 2:STE 310
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85741-3552
Practice Address - Country:US
Practice Address - Phone:520-219-9125
Practice Address - Fax:520-219-9130
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39770208600000X
AZ44536208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64113251Medicaid
KY000000377241OtherANTHEM
KY50008747OtherPASSPORT
KY2646385000OtherPASSPORT ADVANTAGE
KY2646385000OtherPASSPORT ADVANTAGE
142938Medicare UPIN
KY0301509Medicare PIN