Basic Information
| Provider Information | |||||||||
| NPI: | 1447282058 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OCONNOR | ||||||||
| FirstName: | GERALD | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1411 N FLAGLER DR | ||||||||
| Address2: | SUITE 6200 | ||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334013404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5616591238 | ||||||||
| FaxNumber: | 5616590492 | ||||||||
| Practice Location | |||||||||
| Address1: | 1411 N FLAGLER DR | ||||||||
| Address2: | SUITE 6200 | ||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334013404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5616591238 | ||||||||
| FaxNumber: | 5616590492 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 05/11/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | ME31871 | FL | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 257543400 | 05 | FL | MEDICAID |