Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 2301007586 | MI |
NPI | 1225052012 |
---|---|
Provider Name | Dr. Kevin James Donathan |
First Address | Riverview, MI 48193-6630 |
Second Address | Riverview, MI 48193-6630 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/07/2006 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
4673483 | (05) | MI |
99441 | (02) | MI |