Healthcare Provider Details

I. General information

NPI: 1487723300
Provider Name (Legal Business Name): LISA M O'DONNELL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 08/08/2025
Certification Date: 08/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 ELM AVE
HACKENSACK NJ
07601-4701
US

IV. Provider business mailing address

22 ELM AVE
HACKENSACK NJ
07601-4701
US

V. Phone/Fax

Practice location:
  • Phone: 201-267-0890
  • Fax: 201-343-4635
Mailing address:
  • Phone: 201-267-0890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA07968400
License Number StateNJ

VII. Legacy identifiers

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

# 1
Identifier0279676
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: