Healthcare Provider Details

I. General information

NPI: 1144333105
Provider Name (Legal Business Name): ERICA L. O'DONNELL DOPA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 HAND AVE SUITE K
ORMOND BEACH FL
32174-8194
US

IV. Provider business mailing address

1400 HAND AVE SUITE K
ORMOND BEACH FL
32174-8194
US

V. Phone/Fax

Practice location:
  • Phone: 386-673-0517
  • Fax: 386-671-6458
Mailing address:
  • Phone: 386-673-0517
  • Fax: 386-671-6458

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License NumberOS7905
License Number StateFL

VIII. Authorized Official

Name: ERICA LYNNE O'DONNELL
Title or Position: PRESIDENT
Credential: D.O.
Phone: 386-673-0517