=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588660435
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN P DONAHUE MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/24/2005
-----------------------------------------------------
Last Update Date | 01/07/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2909 MAIN ST
-----------------------------------------------------
City | STRATFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06614-4960
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-683-4570
-----------------------------------------------------
Fax | 203-378-4788
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 6128
-----------------------------------------------------
City | BRIDGEPORT
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06606-0128
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-683-4500
-----------------------------------------------------
Fax | 203-926-1410
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 034161
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------