Provider Demographics
NPI:1467983833
Name:ODATHIL, FELIX JOLLY (MD)
Entity Type:Individual
Prefix:
First Name:FELIX
Middle Name:JOLLY
Last Name:ODATHIL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:FELIX
Other - Middle Name:
Other - Last Name:JOLLY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:3 NEENAH CTR
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-3070
Mailing Address - Country:US
Mailing Address - Phone:920-454-4229
Mailing Address - Fax:920-993-5001
Practice Address - Street 1:1405 MILL ST
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:WI
Practice Address - Zip Code:54961-2155
Practice Address - Country:US
Practice Address - Phone:920-531-2000
Practice Address - Fax:920-531-2450
Is Sole Proprietor?:No
Enumeration Date:2017-03-27
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI73944207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty