Provider Demographics
NPI:1033257431
Name:O'CONNOR, MICHAEL KEVIN (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:KEVIN
Last Name:O'CONNOR
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 1:30 BERGEN ST
Mailing Address - Street 2:ADMC 12 1205
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07107-3000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:183 SOUTH ORANGE AVENUE
Practice Address - Street 2:SUITE E1559
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07107-3000
Practice Address - Country:US
Practice Address - Phone:973-972-2977
Practice Address - Fax:973-972-2979
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2009-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07734100207R00000X, 2084P0800X, 2084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0050199Medicaid
NJ0050199Medicaid
NJ085648Medicare PIN