Basic Information
| Provider Information | |||||||||
| NPI: | 1417345745 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | O'DONNELL | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | MARY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | O. D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | OBER | ||||||||
| OtherFirstName: | KATHLEEN | ||||||||
| OtherMiddleName: | MARY | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | O. D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1950 OLD GALLOWS RD STE 520 | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221823970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038478899 | ||||||||
| FaxNumber: | 5712236780 | ||||||||
| Practice Location | |||||||||
| Address1: | 4605 KIRKWOOD HWY STE A | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | DE | ||||||||
| PostalCode: | 198085005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3029997171 | ||||||||
| FaxNumber: | 3029937863 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2015 | ||||||||
| LastUpdateDate: | 02/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | I3-0001374 | DE | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.