Healthcare Provider Details

I. General information

NPI: 1588693998
Provider Name (Legal Business Name): ROBERT J O'DONNELL PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 08/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

632 WESTERN AVE
ALBANY NY
12203-1830
US

IV. Provider business mailing address

632 WESTERN AVE
ALBANY NY
12203-1830
US

V. Phone/Fax

Practice location:
  • Phone: 518-689-0888
  • Fax: 518-689-0889
Mailing address:
  • Phone: 518-689-0888
  • Fax: 518-689-0889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number022928-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: