Provider Demographics
NPI:1699752774
Name:RUNYAN, DONOVAN D (MD)
Entity type:Individual
Prefix:
First Name:DONOVAN
Middle Name:D
Last Name:RUNYAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DONOVAN
Other - Middle Name:D
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2555 WESTERN TRAILS BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-1574
Mailing Address - Country:US
Mailing Address - Phone:888-663-6331
Mailing Address - Fax:415-252-7176
Practice Address - Street 1:2555 WESTERN TRAILS BLVD STE 101
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-1574
Practice Address - Country:US
Practice Address - Phone:888-663-6331
Practice Address - Fax:415-252-7176
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM2113207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXI39778Medicare UPIN
TXI39778Medicare UPIN