Provider Demographics
NPI:1699775700
Name:O CONNOR, JOHN JOSEPH JR (CPO)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:JOSEPH
Last Name:O CONNOR
Suffix:JR
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 S HAWTHORNE RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-4417
Mailing Address - Country:US
Mailing Address - Phone:336-724-6871
Mailing Address - Fax:336-724-6871
Practice Address - Street 1:900 S HAWTHORNE RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-4417
Practice Address - Country:US
Practice Address - Phone:336-724-6871
Practice Address - Fax:336-724-6871
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCPNO695222Z00000X, 224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0495 BOtherBLUE CROSS BLUE SHIELD
NC7700250Medicaid
NC0130040001Medicare NSC