Healthcare Provider Details

I. General information

NPI: 1689685786
Provider Name (Legal Business Name): TIMOTHY ROGERS OCONNELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 09/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 SOUTH NEW BALLAS ROAD SUITE 6003B
SAINT LOUIS MO
63141
US

IV. Provider business mailing address

621 SOUTH NEW BALLAS ROAD SUITE 6003B
SAINT LOUIS MO
63141
US

V. Phone/Fax

Practice location:
  • Phone: 314-991-2151
  • Fax: 314-991-2742
Mailing address:
  • Phone: 314-991-2151
  • Fax: 314-991-2742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number34187
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: