Provider Demographics
NPI:1689966301
Name:DONOVAN, COLIN MATTHEW (DO)
Entity type:Individual
Prefix:
First Name:COLIN
Middle Name:MATTHEW
Last Name:DONOVAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 RICHMOND DR NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-1830
Mailing Address - Country:US
Mailing Address - Phone:817-658-3891
Mailing Address - Fax:
Practice Address - Street 1:1720 LOUISIANA BLVD NE
Practice Address - Street 2:SUITE 401
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-7022
Practice Address - Country:US
Practice Address - Phone:505-260-4300
Practice Address - Fax:505-260-4338
Is Sole Proprietor?:No
Enumeration Date:2011-05-13
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA390200000X
NM390200000X
NMA-1995-16207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program