Provider Demographics
NPI:1083973374
Name:O'CONNELL, RYAN T (DO)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:T
Last Name:O'CONNELL
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 1:955 ROCKY KNOLL LN
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24541-8900
Mailing Address - Country:US
Mailing Address - Phone:315-723-4320
Mailing Address - Fax:
Practice Address - Street 1:120 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541
Practice Address - Country:US
Practice Address - Phone:315-723-4320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-08
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0116024095207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1083973374Medicaid
VAPENDINGMedicare PIN