Healthcare Provider Details

I. General information

NPI: 1063832020
Provider Name (Legal Business Name): ROBERT O'CONNELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2014
Last Update Date: 11/17/2023
Certification Date: 11/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 CLINIC AVE STE 101
CARROLLTON GA
30117-4402
US

IV. Provider business mailing address

150 CLINIC AVE STE 101
CARROLLTON GA
30117-4402
US

V. Phone/Fax

Practice location:
  • Phone: 770-834-0873
  • Fax: 770-834-6118
Mailing address:
  • Phone: 770-834-0873
  • Fax: 770-834-6118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number97890
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: