Provider Demographics
NPI:1427168509
Name:O'CONNELL, MICHAEL ROBERT (DC)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ROBERT
Last Name:O'CONNELL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 W PINE ST
Mailing Address - Street 2:STE 14
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-2048
Mailing Address - Country:US
Mailing Address - Phone:209-333-3332
Mailing Address - Fax:209-367-8504
Practice Address - Street 1:404 W PINE ST
Practice Address - Street 2:STE 14
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-2048
Practice Address - Country:US
Practice Address - Phone:209-333-3332
Practice Address - Fax:209-367-8504
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC14176111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6628712Medicaid
CA6628712Medicaid
TO5270Medicare UPIN