Healthcare Provider Details

I. General information

NPI: 1548721756
Provider Name (Legal Business Name): MAMEYAN DONZO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2019
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 E 1ST ST
DIXON IL
61021-3116
US

IV. Provider business mailing address

9050 CYPRESS GREEN DR STE 104
JACKSONVILLE FL
32256-5517
US

V. Phone/Fax

Practice location:
  • Phone: 815-285-5629
  • Fax: 815-285-5634
Mailing address:
  • Phone: 904-486-2055
  • Fax: 904-486-2055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME159277
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberME159277
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036162923
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: