Basic Information
| Provider Information | |||||||||
| NPI: | 1437122793 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DONOVAN | ||||||||
| FirstName: | GERARD | ||||||||
| MiddleName: | KEVIN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 418283 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022418283 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7035581400 | ||||||||
| FaxNumber: | 7035581445 | ||||||||
| Practice Location | |||||||||
| Address1: | 3800 RESERVOIR RD NW | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200072113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2024448518 | ||||||||
| FaxNumber: | 2024447161 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2006 | ||||||||
| LastUpdateDate: | 02/15/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0206X | 10680 | OK | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology | 208000000X | MD040672 | DC | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 100629430C | 05 | OK | MEDICAID |