1669447207 NPI number — KENNETH WAYNE DONOVAN M.D.

Table of content: DR. JON W SUSOTT DDS (NPI 1073626230)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669447207 NPI number — KENNETH WAYNE DONOVAN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DONOVAN
Provider First Name:
KENNETH
Provider Middle Name:
WAYNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669447207
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/11/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
28 CRESCENT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIDDLETOWN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06457-3654
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-358-6000
Provider Business Mailing Address Fax Number:
860-358-8661

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
35 SAYBROOK RD
Provider Second Line Business Practice Location Address:
UNIT 6
Provider Business Practice Location Address City Name:
ESSEX
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06426-1490
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-358-3725
Provider Business Practice Location Address Fax Number:
860-358-3726
Provider Enumeration Date:
02/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  042916 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X , with the licence number: MD12478 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 001429168 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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