Healthcare Provider Details

I. General information

NPI: 1215930722
Provider Name (Legal Business Name): MICHAEL J O'DONNELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2005
Last Update Date: 02/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

327 N WASHINGTON AVE STE 200
SCRANTON PA
18503-1535
US

IV. Provider business mailing address

327 N WASHINGTON AVE STE 200
SCRANTON PA
18503-1535
US

V. Phone/Fax

Practice location:
  • Phone: 570-961-5522
  • Fax: 570-207-5579
Mailing address:
  • Phone: 570-961-5522
  • Fax: 570-207-5579

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD041957E
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberMD041957E
License Number StatePA

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: