Healthcare Provider Details

I. General information

NPI: 1285656413
Provider Name (Legal Business Name): BRIAN PATRICK O'DONNELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 07/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 US ROUTE 1
FREEPORT ME
04032-7023
US

IV. Provider business mailing address

407 US ROUTE 1
FREEPORT ME
04032-7023
US

V. Phone/Fax

Practice location:
  • Phone: 207-865-2023
  • Fax: 207-865-2027
Mailing address:
  • Phone: 207-865-2023
  • Fax: 207-865-2027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberMD13824
License Number StateME

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier010527189
Identifier TypeMEDICAID
Identifier StateME
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: