Healthcare Provider Details

I. General information

NPI: 1730324096
Provider Name (Legal Business Name): LYDIA JOY DONOGHUE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2008
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 BEAUBIEN ST DEPT OF PEDIATRIC SURGERY
DETROIT MI
48201-2119
US

IV. Provider business mailing address

8234 JOHN R
DETROIT MI
48202-2506
US

V. Phone/Fax

Practice location:
  • Phone: 313-831-3220
  • Fax: 313-745-0747
Mailing address:
  • Phone: 248-219-5620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number35095454
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number4301077977
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: