Healthcare Provider Details

I. General information

NPI: 1548947971
Provider Name (Legal Business Name): O'CONNELL CALEB PENROSE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2023
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2050A 2ND ST SE
ALBUQUERQUE NM
87117-5522
US

IV. Provider business mailing address

2050A 2ND ST SE
ALBUQUERQUE NM
87117-5522
US

V. Phone/Fax

Practice location:
  • Phone: 843-996-9027
  • Fax:
Mailing address:
  • Phone: 843-996-9027
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number2026032184
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: