Provider Demographics
NPI:1629245790
Name:O'CONNELL, TARA (MD)
Entity type:Individual
Prefix:DR
First Name:TARA
Middle Name:
Last Name:O'CONNELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 720300
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73172-0300
Mailing Address - Country:US
Mailing Address - Phone:800-749-4560
Mailing Address - Fax:405-751-3183
Practice Address - Street 1:4870 BARRANCA PKWY
Practice Address - Street 2:ECU DEPT
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-4709
Practice Address - Country:US
Practice Address - Phone:949-451-6006
Practice Address - Fax:405-751-3183
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-08
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA107639207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1629245790Medicaid
CACD235XMedicare PIN