Healthcare Provider Details

I. General information

NPI: 1942264262
Provider Name (Legal Business Name): MARY OCONNELL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12900 NE 180 STREET SUITE 100
BOTHELL WA
98011
US

IV. Provider business mailing address

12900 NE 180 STREET SUITE 100
BOTHELL WA
98011
US

V. Phone/Fax

Practice location:
  • Phone: 425-398-9355
  • Fax: 425-486-5913
Mailing address:
  • Phone: 425-398-9355
  • Fax: 425-486-5913

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberMD00026764
License Number StateWA

VII. Legacy identifiers

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

# 1
Identifier1072487
Identifier TypeMEDICAID
Identifier StateWA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: