Healthcare Provider Details

I. General information

NPI: 1588660435
Provider Name (Legal Business Name): JOHN P DONAHUE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 01/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2909 MAIN ST
STRATFORD CT
06614-4960
US

IV. Provider business mailing address

PO BOX 6128
BRIDGEPORT CT
06606-0128
US

V. Phone/Fax

Practice location:
  • Phone: 203-683-4570
  • Fax: 203-378-4788
Mailing address:
  • Phone: 203-683-4500
  • Fax: 203-926-1410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number034161
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: