1992095467 NPI number — DR. STEPHANIE JILL DONOVAN DPM

Table of content: DR. STEPHANIE JILL DONOVAN DPM (NPI 1992095467)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992095467 NPI number — DR. STEPHANIE JILL DONOVAN DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DONOVAN
Provider First Name:
STEPHANIE
Provider Middle Name:
JILL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
F

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:
1992095467
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/02/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
990 W ANN ARBOR TRL
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
PLYMOUTH
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48170-6204
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-414-0874
Provider Business Mailing Address Fax Number:
734-414-0875

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
990 W ANN ARBOR TRL
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
PLYMOUTH
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48170-6204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-414-0874
Provider Business Practice Location Address Fax Number:
734-414-0875
Provider Enumeration Date:
04/18/2011

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: 213E00000X , with the licence number:  5901002407 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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