Provider Demographics
NPI:1992969117
Name:O'DEA, COLIN MAGNUSON (MD)
Entity type:Individual
Prefix:
First Name:COLIN
Middle Name:MAGNUSON
Last Name:O'DEA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1614 MOUNT VERNON ST
Mailing Address - Street 2:APT 2
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-3340
Mailing Address - Country:US
Mailing Address - Phone:812-219-0066
Mailing Address - Fax:
Practice Address - Street 1:BROAD AND VINE STREETS
Practice Address - Street 2:MAIL STOP 623
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102
Practice Address - Country:US
Practice Address - Phone:215-762-2618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-16
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT193425207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine