Provider Demographics
NPI:1093332389
Name:DONOVITCH, MYRIAM JACYNTHE (MD)
Entity type:Individual
Prefix:DR
First Name:MYRIAM
Middle Name:JACYNTHE
Last Name:DONOVITCH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MYRIAM
Other - Middle Name:JACYNTHE
Other - Last Name:BENOIT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:7401 104TH AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-7845
Mailing Address - Country:US
Mailing Address - Phone:262-764-5891
Mailing Address - Fax:
Practice Address - Street 1:7401 104TH AVE STE 110
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-7845
Practice Address - Country:US
Practice Address - Phone:262-764-5595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-02
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI83968-20207QS0010X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine