Provider Demographics
NPI:1194770933
Name:O'DELL, DWIGHT WILLIAM (MD)
Entity type:Individual
Prefix:DR
First Name:DWIGHT
Middle Name:WILLIAM
Last Name:O'DELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:4550 MEMORIAL DR
Mailing Address - Street 2:STE 200
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-5359
Mailing Address - Country:US
Mailing Address - Phone:618-233-5998
Mailing Address - Fax:618-233-6001
Practice Address - Street 1:4550 MEMORIAL DR
Practice Address - Street 2:STE 200
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5359
Practice Address - Country:US
Practice Address - Phone:618-233-5998
Practice Address - Fax:618-233-6001
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2007-09-18
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK31263Medicare PIN
ILC46175Medicare UPIN