Provider Demographics
NPI:1194717744
Name:DONOVAN, MARY B (MD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:B
Last Name:DONOVAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2010 ATHERHOLT RD
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-1106
Mailing Address - Country:US
Mailing Address - Phone:434-200-3656
Mailing Address - Fax:
Practice Address - Street 1:412 NAMOZINE STREET
Practice Address - Street 2:
Practice Address - City:BURKEVILLE
Practice Address - State:VA
Practice Address - Zip Code:23922
Practice Address - Country:US
Practice Address - Phone:434-767-5511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101032621207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1580808OtherCIGNA
VA5698529Medicaid
VA61459602OtherBLACK LUNG/FECA
VA345646OtherANTHEM
VA4578020OtherAETNA
VA1194717744Medicaid
VA345646OtherANTHEM
VAP00606595Medicare PIN
VA4578020OtherAETNA
VA1194717744Medicaid