Provider Demographics
NPI:1144333105
Name:ERICA L. O'DONNELL DOPA
Entity type:Organization
Organization Name:ERICA L. O'DONNELL DOPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:LYNNE
Authorized Official - Last Name:O'DONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:386-673-0517
Mailing Address - Street 1:1400 HAND AVE
Mailing Address - Street 2:SUITE K
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-8194
Mailing Address - Country:US
Mailing Address - Phone:386-673-0517
Mailing Address - Fax:386-671-6458
Practice Address - Street 1:1400 HAND AVE
Practice Address - Street 2:SUITE K
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-8194
Practice Address - Country:US
Practice Address - Phone:386-673-0517
Practice Address - Fax:386-671-6458
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7905207QA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL01768OtherBLUE CROSS
FL7512263OtherAETNA
FL80184473OtherTRICARE RAILROAD
H43025Medicare UPIN
FL7512263OtherAETNA