Healthcare Provider Details

I. General information

NPI: 1255358842
Provider Name (Legal Business Name): THOMAS J DONOVAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 01/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3660 VISTA
ST LOUIS MO
63110
US

IV. Provider business mailing address

3691 RUTGER AVE PROVIDER ENROLLMENT
ST LOUIS MO
63110
US

V. Phone/Fax

Practice location:
  • Phone: 314-577-8887
  • Fax: 314-268-5111
Mailing address:
  • Phone: 314-977-4440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberR5161
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License NumberR5161
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: