Healthcare Provider Details

I. General information

NPI: 1205890282
Provider Name (Legal Business Name): JOHN THORNTON O'DONNELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2006
Last Update Date: 01/05/2023
Certification Date: 01/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11215 METRO PKWY STE 1
FORT MYERS FL
33966-1206
US

IV. Provider business mailing address

11215 METRO PKWY STE 1
FORT MYERS FL
33966-1206
US

V. Phone/Fax

Practice location:
  • Phone: 239-208-2212
  • Fax:
Mailing address:
  • Phone: 239-208-2212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number158850
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberMA059107
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMA059107
License Number StateNJ
# 4
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number158850
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: