Basic Information
Provider Information | |||||||||
NPI: | 1407825433 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ODONNELL | ||||||||
FirstName: | PAUL | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 593 | ||||||||
Address2: |   | ||||||||
City: | CAPE MAY COURT HOUSE | ||||||||
State: | NJ | ||||||||
PostalCode: | 082100593 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6094632755 | ||||||||
FaxNumber: | 6094632757 | ||||||||
Practice Location | |||||||||
Address1: | 217 N MAIN ST | ||||||||
Address2: | SUITE 104 | ||||||||
City: | CAPE MAY COURT HOUSE | ||||||||
State: | NJ | ||||||||
PostalCode: | 082102165 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6094631488 | ||||||||
FaxNumber: | 6094634881 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/14/2006 | ||||||||
LastUpdateDate: | 09/22/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | 25MB083768000 | NJ | Y |   | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 2086S0129X | OS010515L | PA | N |   | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
ID | Type | State | Issuer | Description | BO8907618 | 01 |   | DEA | OTHER |