1508851361 NPI number — DR. JOSEPH J O'DONNELL M.D.

Table of content: DR. JOSEPH J O'DONNELL M.D. (NPI 1508851361)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508851361 NPI number — DR. JOSEPH J O'DONNELL M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
O'DONNELL
Provider First Name:
JOSEPH
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1508851361
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/16/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4150 NELSON RD
Provider Second Line Business Mailing Address:
BUILDING G, SUITE 3
Provider Business Mailing Address City Name:
LAKE CHARLES
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70605-4148
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-562-3732
Provider Business Mailing Address Fax Number:
337-562-3699

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4150 NELSON RD
Provider Second Line Business Practice Location Address:
BUILDING G, SUITE 3
Provider Business Practice Location Address City Name:
LAKE CHARLES
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70605-4148
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-562-3732
Provider Business Practice Location Address Fax Number:
337-562-3699
Provider Enumeration Date:
09/16/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  08602R , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1910830 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4601931 . This is a "AETNA" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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