Healthcare Provider Details

I. General information

NPI: 1215912803
Provider Name (Legal Business Name): LAURA O'DONNELL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2005
Last Update Date: 10/25/2020
Certification Date: 09/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

656 CARPENTER AVE
MOORESVILLE NC
28115-2538
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 704-664-5133
  • Fax:
Mailing address:
  • Phone: 844-266-8268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number200301394
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number200301394
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: