Basic Information
| Provider Information | |||||||||
| NPI: | 1730494741 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | O'CONNELL | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4700 LAS VEGAS BLVD N | ||||||||
| Address2: | |||||||||
| City: | NELLIS AFB | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891916600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7026533050 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1707 W CHARLESTON BLVD STE 160 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891022354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7026715150 | ||||||||
| FaxNumber: | 7026712259 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2010 | ||||||||
| LastUpdateDate: | 05/26/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 2013-02230 | NC | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 268463 | MA | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0127X | 20465 | NV | Y | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1832R | 01 | NC | BCBS NC | OTHER | 1730494741 | 05 | NC | MEDICAID |