Provider Demographics
NPI:1467500447
Name:O'DONNELL, THERESA M (MD)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:M
Last Name:O'DONNELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2030 BLUEGRASS CIR
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-7328
Mailing Address - Country:US
Mailing Address - Phone:307-635-3500
Mailing Address - Fax:307-635-4642
Practice Address - Street 1:2030 BLUEGRASS CIR
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-7328
Practice Address - Country:US
Practice Address - Phone:307-635-3500
Practice Address - Fax:307-635-4642
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY8775A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine