Healthcare Provider Details

I. General information

NPI: 1386930493
Provider Name (Legal Business Name): BENJAMIN T O'CONNELL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2011
Last Update Date: 06/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2627 RIVERSIDE AVE
JACKSONVILLE FL
32204-4712
US

IV. Provider business mailing address

2627 RIVERSIDE AVE
JACKSONVILLE FL
32204-4712
US

V. Phone/Fax

Practice location:
  • Phone: 904-308-7372
  • Fax: 904-308-2908
Mailing address:
  • Phone: 904-308-7372
  • Fax: 904-308-2908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberUO 2893
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: