Provider Demographics
NPI:1316974132
Name:O'DEA, DOUGLAS LAWRENCE (MD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:LAWRENCE
Last Name:O'DEA
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:PO BOX 902, DEPT 100
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38101-0902
Mailing Address - Country:US
Mailing Address - Phone:901-757-2791
Mailing Address - Fax:901-757-9065
Practice Address - Street 1:7378 YALE RD
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38133-3604
Practice Address - Country:US
Practice Address - Phone:901-387-0193
Practice Address - Fax:901-387-0796
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000018194207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0108564OtherBLUECROSS OF TENNESSEE
TN3027190Medicaid
TN3027195Medicare ID - Type Unspecified
TN3027190Medicaid