Healthcare Provider Details

I. General information

NPI: 1730494741
Provider Name (Legal Business Name): BRIAN J O'CONNELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2010
Last Update Date: 05/26/2021
Certification Date: 05/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1707 W CHARLESTON BLVD STE 160
LAS VEGAS NV
89102-2354
US

IV. Provider business mailing address

4700 LAS VEGAS BLVD N
NELLIS AFB NV
89191-6600
US

V. Phone/Fax

Practice location:
  • Phone: 702-671-5150
  • Fax: 702-671-2259
Mailing address:
  • Phone: 702-653-3050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2013-02230
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number268463
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number20465
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: