Provider Demographics
NPI:1033118427
Name:ODONNELL, BRIAN DAVID (OD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:DAVID
Last Name:ODONNELL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1324 MEMORIAL HWY
Mailing Address - Street 2:
Mailing Address - City:SHAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18708-1545
Mailing Address - Country:US
Mailing Address - Phone:570-704-3993
Mailing Address - Fax:570-704-3998
Practice Address - Street 1:1324 MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:SHAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:18708-1545
Practice Address - Country:US
Practice Address - Phone:570-704-3993
Practice Address - Fax:570-704-3998
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-18
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000463152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1012666000001Medicaid
PA1012666000001Medicaid
PA5432210001Medicare NSC
PA068569ZLFSMedicare PIN