Healthcare Provider Details

I. General information

NPI: 1336129378
Provider Name (Legal Business Name): JEFFREY DOUGLAS O'DELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 04/20/2023
Certification Date: 04/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1355 MARINERS DR
WARSAW IN
46582-7145
US

IV. Provider business mailing address

11109 PARKVIEW PLAZA DR # 117
FORT WAYNE IN
46845-1701
US

V. Phone/Fax

Practice location:
  • Phone: 574-267-6778
  • Fax: 574-267-3134
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101232521
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01084702A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: