Healthcare Provider Details

I. General information

NPI: 1396317707
Provider Name (Legal Business Name): DR. THOMAS JOHN O'DONNELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2021
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 PROFESSIONAL PARK DR STE 11
JOHNSON CITY TN
37604-6584
US

IV. Provider business mailing address

2 PROFESSIONAL PARK DR STE 11
JOHNSON CITY TN
37604-6584
US

V. Phone/Fax

Practice location:
  • Phone: 423-439-6464
  • Fax:
Mailing address:
  • Phone: 423-439-6464
  • Fax: 423-922-9337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC1-0029374
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: