Healthcare Provider Details

I. General information

NPI: 1891795175
Provider Name (Legal Business Name): JOHN P ODONNELL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 08/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

173 NW ALBRITTON LN
LAKE CITY FL
32055-4451
US

IV. Provider business mailing address

8622 133RD LN
LIVE OAK FL
32060-8837
US

V. Phone/Fax

Practice location:
  • Phone: 386-755-4020
  • Fax:
Mailing address:
  • Phone: 386-208-4084
  • Fax: 386-752-9143

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA3548
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: