Provider Demographics
NPI:1194999763
Name:BRIAN ODONNELL, OD PC
Entity type:Organization
Organization Name:BRIAN ODONNELL, OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:O'DONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:570-826-8918
Mailing Address - Street 1:226 CAREY AVE
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18702-2113
Mailing Address - Country:US
Mailing Address - Phone:570-826-8918
Mailing Address - Fax:570-826-0240
Practice Address - Street 1:226 CAREY AVE
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-2113
Practice Address - Country:US
Practice Address - Phone:570-826-8918
Practice Address - Fax:570-826-0240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-15
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000463152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1012666000001Medicaid
PAU34570Medicare UPIN
PA094650Medicare PIN
PA1012666000001Medicaid