Provider Demographics
NPI:1699771667
Name:OCONNELL, KEITH (DC)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:
Last Name:OCONNELL
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 1:61 CRESCENT AVE
Mailing Address - Street 2:STE B
Mailing Address - City:WALDWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:07463-1400
Mailing Address - Country:US
Mailing Address - Phone:201-444-1988
Mailing Address - Fax:201-444-8709
Practice Address - Street 1:61 CRESCENT AVE
Practice Address - Street 2:STE B
Practice Address - City:WALDWICK
Practice Address - State:NJ
Practice Address - Zip Code:07463-1400
Practice Address - Country:US
Practice Address - Phone:201-444-1988
Practice Address - Fax:201-444-8709
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-24
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00268600111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5231400Medicaid
NJX4139110OtherEMPIRE BCBS
NJT45019Medicare UPIN
NJ444593Medicare ID - Type UnspecifiedPROVIDER #