Provider Demographics
NPI:1194748962
Name:O'DONOGHUE, MICHAEL KEVIN (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:KEVIN
Last Name:O'DONOGHUE
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 1:2434 WOLF RD
Mailing Address - Street 2:
Mailing Address - City:WESTCHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:60154-5634
Mailing Address - Country:US
Mailing Address - Phone:708-562-5430
Mailing Address - Fax:
Practice Address - Street 1:2434 WOLF RD
Practice Address - Street 2:
Practice Address - City:WESTCHESTER
Practice Address - State:IL
Practice Address - Zip Code:60154-5634
Practice Address - Country:US
Practice Address - Phone:708-562-5430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL03-113995207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL2486008Medicare PIN
INM400071202Medicare PIN
ILIL2485008Medicare PIN