Provider Demographics
NPI:1417345745
Name:O'DONNELL, KATHLEEN MARY (O D)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARY
Last Name:O'DONNELL
Suffix:
Gender:F
Credentials:O D
Other - Prefix:MRS
Other - First Name:KATHLEEN
Other - Middle Name:MARY
Other - Last Name:OBER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:O D
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:4605 KIRKWOOD HWY STE A
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19808-5005
Practice Address - Country:US
Practice Address - Phone:302-999-7171
Practice Address - Fax:302-993-7863
Is Sole Proprietor?:No
Enumeration Date:2015-01-09
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEI3-0001374152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U43085Medicare UPIN