Provider Demographics
NPI:1124029582
Name:ODONNELL, MICHAEL A (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:A
Last Name:ODONNELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 HAWKINS DR
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1009
Mailing Address - Country:US
Mailing Address - Phone:319-384-6981
Mailing Address - Fax:319-356-3900
Practice Address - Street 1:200 HAWKINS DR
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1009
Practice Address - Country:US
Practice Address - Phone:319-384-6981
Practice Address - Fax:319-356-3900
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA33583208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA19984OtherWELLMARK BCBS
IA0212456Medicaid
IA19984OtherWELLMARK BCBS
A14276Medicare UPIN