Healthcare Provider Details

I. General information

NPI: 1992792261
Provider Name (Legal Business Name): SCOTT B O'CONNOR D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 02/04/2025
Certification Date: 02/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1512 W REYNOLDS ST STE A
PONTIAC IL
61764-9788
US

IV. Provider business mailing address

1512 W REYNOLDS ST STE A
PONTIAC IL
61764-9788
US

V. Phone/Fax

Practice location:
  • Phone: 815-842-6551
  • Fax:
Mailing address:
  • Phone: 815-842-6551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number016005106
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: