Provider Demographics
NPI:1285656413
Name:O'DONNELL, BRIAN PATRICK (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:PATRICK
Last Name:O'DONNELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 US ROUTE 1
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04032-7023
Mailing Address - Country:US
Mailing Address - Phone:207-865-2023
Mailing Address - Fax:207-865-2027
Practice Address - Street 1:407 US ROUTE 1
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:ME
Practice Address - Zip Code:04032-7023
Practice Address - Country:US
Practice Address - Phone:207-865-2023
Practice Address - Fax:207-865-2027
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD13824207ND0101X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME010527189Medicaid
MEF67782Medicare UPIN