Provider Demographics
NPI:1245208446
Name:O'DONNELL, JOHN L (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:L
Last Name:O'DONNELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3673 SOUTHWESTERN BLVD
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-1740
Mailing Address - Country:US
Mailing Address - Phone:716-662-8083
Mailing Address - Fax:716-667-2150
Practice Address - Street 1:3673 SOUTHWESTERN BLVD
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-1740
Practice Address - Country:US
Practice Address - Phone:716-662-8083
Practice Address - Fax:716-667-2150
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY189230207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01414882Medicaid
NY5244061OtherBLUE CROSS & BLUE SHIELD
0905599OtherINDEPENDENT HEALTH
NY5244061OtherBLUE CROSS & BLUE SHIELD
NY01414882Medicaid