Healthcare Provider Details

I. General information

NPI: 1629217633
Provider Name (Legal Business Name): MARK JAMES DONOVAN D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2009
Last Update Date: 03/10/2025
Certification Date: 03/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 WISCONSIN AMERICAN DR
FOND DU LAC WI
54937-2999
US

IV. Provider business mailing address

210 WISCONSIN AMERICAN DR
FOND DU LAC WI
54937-2999
US

V. Phone/Fax

Practice location:
  • Phone: 920-907-7000
  • Fax:
Mailing address:
  • Phone: 920-907-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number4476-12
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: