=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124081591
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN MARK DONOVAN M.O.T.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/07/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1501 SAN PEDRO DR SE
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87108-5153
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-265-1711
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 10123
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87184-0123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-265-1711
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 2132
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------