Healthcare Provider Details

I. General information

NPI: 1043476450
Provider Name (Legal Business Name): M. KEVIN O'CONNOR MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2008
Last Update Date: 08/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 MILLBURN AVE SUITE 210
MILLBURN NJ
07041-1737
US

IV. Provider business mailing address

225 MILLBURN AVE SUITE 210
MILLBURN NJ
07041-1737
US

V. Phone/Fax

Practice location:
  • Phone: 973-912-0200
  • Fax: 973-376-8039
Mailing address:
  • Phone: 973-912-0200
  • Fax: 973-376-8039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number25MA07734100
License Number StateNJ

VIII. Authorized Official

Name: MICHAEL KEVIN O'CONNOR
Title or Position: OWNER
Credential: MD
Phone: 973-912-0200