Provider Demographics
NPI:1083689061
Name:O'BRIEN, JOHN J (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:J
Last Name:O'BRIEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2630 HIGHWAY K
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-6624
Mailing Address - Country:US
Mailing Address - Phone:636-240-5454
Mailing Address - Fax:
Practice Address - Street 1:2630 HIGHWAY K
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-6624
Practice Address - Country:US
Practice Address - Phone:636-240-5454
Practice Address - Fax:618-980-5335
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR3E76207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO080171320OtherRAILROAD MEDICARE
D77797Medicare UPIN
MO080171320OtherRAILROAD MEDICARE