Healthcare Provider Details

I. General information

NPI: 1578478277
Provider Name (Legal Business Name): CAMERON DONOVAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11725 FOX RD
INDIANAPOLIS IN
46236-8424
US

IV. Provider business mailing address

2122 YORK RD STE 300
OAK BROOK IL
60523-1925
US

V. Phone/Fax

Practice location:
  • Phone: 317-855-6500
  • Fax:
Mailing address:
  • Phone: 803-812-3656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05016518A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: