Provider Demographics
NPI:1699771725
Name:O'DONNELL, SHERRELL A (DO)
Entity type:Individual
Prefix:DR
First Name:SHERRELL
Middle Name:A
Last Name:O'DONNELL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3911 STONEGATE PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-8623
Mailing Address - Country:US
Mailing Address - Phone:269-408-1777
Mailing Address - Fax:269-408-1755
Practice Address - Street 1:3911 STONEGATE PARK DRIVE
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-8623
Practice Address - Country:US
Practice Address - Phone:269-408-1777
Practice Address - Fax:269-408-1755
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101014079207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4507301Medicaid
MI4507301Medicaid
MIG45956Medicare UPIN