Provider Demographics
NPI:1972517191
Name:O'DONNELL, DAVID (DO)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:O'DONNELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 W WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:OGLESBY
Mailing Address - State:IL
Mailing Address - Zip Code:61348-1400
Mailing Address - Country:US
Mailing Address - Phone:815-883-3588
Mailing Address - Fax:815-883-3604
Practice Address - Street 1:520 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:OGLESBY
Practice Address - State:IL
Practice Address - Zip Code:61348-1400
Practice Address - Country:US
Practice Address - Phone:815-883-3588
Practice Address - Fax:815-883-3604
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS008291L207Q00000X
IL036.130299207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAH05539Medicare UPIN