Provider Demographics
NPI:1861516718
Name:O'CONNELL, JEROME THOMAS JR (MD)
Entity type:Individual
Prefix:DR
First Name:JEROME
Middle Name:THOMAS
Last Name:O'CONNELL
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Mailing Address - Street 1:224-D CORNWALL STREET, NW, SUITE 403
Mailing Address - Street 2:DEPARTMENT OF PATHOLOGY
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-2704
Mailing Address - Country:US
Mailing Address - Phone:703-737-6010
Mailing Address - Fax:703-443-8643
Practice Address - Street 1:2300 OPITZ BLVD
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191
Practice Address - Country:US
Practice Address - Phone:703-670-1835
Practice Address - Fax:703-670-0827
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-18
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD32177207ZP0102X
CAA63118207ZP0102X
MDD0058140207ZP0102X
VA0101231713207ZP0105X, 207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1861516718Medicaid