Provider Demographics
NPI:1275541724
Name:O'DONNELL, MICHAEL T (DPT, OCS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:T
Last Name:O'DONNELL
Suffix:
Gender:M
Credentials:DPT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1294 W 6TH ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-2987
Mailing Address - Country:US
Mailing Address - Phone:310-547-1850
Mailing Address - Fax:310-547-1972
Practice Address - Street 1:1294 W 6TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-2987
Practice Address - Country:US
Practice Address - Phone:310-547-1850
Practice Address - Fax:310-547-1972
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT11977225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW15555Medicare ID - Type UnspecifiedMEDICARE PROVIDER
CAPT11977Medicare UPIN