Healthcare Provider Details

I. General information

NPI: 1619997772
Provider Name (Legal Business Name): KELLY O'DONNELL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 06/20/2023
Certification Date: 05/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

166 DEFENSE HWY SUITE 101
ANNAPOLIS MD
21401-8919
US

IV. Provider business mailing address

166 DEFENSE HWY STE 101
ANNAPOLIS MD
21401-8921
US

V. Phone/Fax

Practice location:
  • Phone: 410-224-3390
  • Fax: 410-224-3370
Mailing address:
  • Phone: 410-224-3390
  • Fax: 410-224-3370

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD32654
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License NumberD0042645
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: