Healthcare Provider Details

I. General information

NPI: 1467983833
Provider Name (Legal Business Name): FELIX JOLLY ODATHIL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: FELIX JOLLY M.D.

II. Dates (important events)

Enumeration Date: 03/27/2017
Last Update Date: 12/14/2020
Certification Date: 12/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 MILL ST
NEW LONDON WI
54961-2155
US

IV. Provider business mailing address

3 NEENAH CTR
NEENAH WI
54956-3070
US

V. Phone/Fax

Practice location:
  • Phone: 920-531-2000
  • Fax: 920-531-2450
Mailing address:
  • Phone: 920-454-4229
  • Fax: 920-993-5001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number73944
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: