Provider Demographics
NPI:1093747115
Name:O'CONNELL, MARK T (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:T
Last Name:O'CONNELL
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1500 NW 12TH AVE
Mailing Address - Street 2:JMT-EAST 1007
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136-1051
Mailing Address - Country:US
Mailing Address - Phone:305-243-4664
Mailing Address - Fax:305-243-9927
Practice Address - Street 1:1611 NW 12TH AVE
Practice Address - Street 2:BOX 016960 M851
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1005
Practice Address - Country:US
Practice Address - Phone:305-585-1111
Practice Address - Fax:305-243-8470
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2013-01-28
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Provider Licenses
StateLicense IDTaxonomies
FLME34709207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0655597-00Medicaid
FL0655597-00Medicaid
D63577Medicare UPIN