Healthcare Provider Details

I. General information

NPI: 1649834862
Provider Name (Legal Business Name): ALEXANDER ANTHONY O'DELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2019
Last Update Date: 08/11/2023
Certification Date: 08/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7399 MIDDLEBELT RD STE 3
WEST BLOOMFIELD MI
48322-4137
US

IV. Provider business mailing address

15014 HOUGHTON ST
LIVONIA MI
48154-4816
US

V. Phone/Fax

Practice location:
  • Phone: 248-780-1695
  • Fax:
Mailing address:
  • Phone: 440-552-3778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301506872
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: