Provider Demographics
NPI:1033110259
Name:O'CONNELL, MICHAEL JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOHN
Last Name:O'CONNELL
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 1:812 PAXTON RD SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55902-6643
Mailing Address - Country:US
Mailing Address - Phone:507-289-3675
Mailing Address - Fax:
Practice Address - Street 1:812 PAXTON RD SW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55902-6643
Practice Address - Country:US
Practice Address - Phone:507-289-3675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2010-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN19215207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018913800001Medicaid
PAE51408Medicare UPIN
PA0018913800001Medicaid