Healthcare Provider Details

I. General information

NPI: 1952783888
Provider Name (Legal Business Name): DONOVAN BLACKWOOD JEFFCOAT D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2015
Last Update Date: 12/22/2021
Certification Date: 12/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 E SHERMAN BLVD SUITE 2400
MUSKEGON MI
49444
US

IV. Provider business mailing address

1150 E SHERMAN BLVD STE 2400
MUSKEGON MI
49444-1886
US

V. Phone/Fax

Practice location:
  • Phone: 231-728-4601
  • Fax: 231-728-4783
Mailing address:
  • Phone: 231-672-6336
  • Fax: 231-672-6335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number5101021948
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: