Provider Demographics
NPI:1669447207
Name:DONOVAN, KENNETH WAYNE (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:WAYNE
Last Name:DONOVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:28 CRESCENT ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-3654
Mailing Address - Country:US
Mailing Address - Phone:860-358-6000
Mailing Address - Fax:860-358-8661
Practice Address - Street 1:35 SAYBROOK RD
Practice Address - Street 2:UNIT 6
Practice Address - City:ESSEX
Practice Address - State:CT
Practice Address - Zip Code:06426-1490
Practice Address - Country:US
Practice Address - Phone:860-358-3725
Practice Address - Fax:860-358-3726
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2025-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT042916207R00000X
RIMD12478207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001429168Medicaid
H38633Medicare UPIN
CT110009409Medicare ID - Type Unspecified