Provider Demographics
NPI:1417969007
Name:O'DELL, MICHAEL (PA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:O'DELL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 GASLIGHT BLVD
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-3166
Mailing Address - Country:US
Mailing Address - Phone:936-634-8800
Mailing Address - Fax:
Practice Address - Street 1:208 GASLIGHT BLVD
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-3166
Practice Address - Country:US
Practice Address - Phone:936-634-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01789363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXS98615Medicare UPIN