Provider Demographics
NPI:1114911492
Name:O'DONNELL, KEVIN WILLIAM (DO)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:WILLIAM
Last Name:O'DONNELL
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:PO BOX 21928
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4116
Mailing Address - Country:US
Mailing Address - Phone:720-463-0567
Mailing Address - Fax:303-494-5371
Practice Address - Street 1:5161 E ARAPAHOE RD STE 250
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80122-4810
Practice Address - Country:US
Practice Address - Phone:720-463-0567
Practice Address - Fax:303-494-5371
Is Sole Proprietor?:No
Enumeration Date:2005-09-01
Last Update Date:2023-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0067561207Q00000X, 207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ335922Medicaid