Healthcare Provider Details

I. General information

NPI: 1578018479
Provider Name (Legal Business Name): TIMOTHY J. DONOVAN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2016
Last Update Date: 08/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 W UNIVERSITY PKWY
LEESVILLE LA
71446-4734
US

IV. Provider business mailing address

103 W UNIVERSITY PKWY
LEESVILLE LA
71446-4734
US

V. Phone/Fax

Practice location:
  • Phone: 337-239-2600
  • Fax: 337-239-2601
Mailing address:
  • Phone: 337-239-2600
  • Fax: 337-239-2601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberAP08929
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License NumberAP08929
License Number StateLA

VIII. Authorized Official

Name: DR. TIMOTHY J. DONOVAN
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 337-239-2600