Provider Demographics
NPI:1083691885
Name:OCONNELL, MICHAEL JAMES (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAMES
Last Name:OCONNELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17960 CLEVELAND RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1349
Mailing Address - Country:US
Mailing Address - Phone:574-287-7205
Mailing Address - Fax:574-232-5045
Practice Address - Street 1:17960 CLEVELAND RD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1349
Practice Address - Country:US
Practice Address - Phone:574-287-7205
Practice Address - Fax:574-232-5045
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02000569A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000095399OtherANTHEM BLUE CROSS
IN737750AMedicare PIN
IN000000095399OtherANTHEM BLUE CROSS