Provider Demographics
NPI:1477618163
Name:O'CONNOR, JOHN JOSEPH (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:JOSEPH
Last Name:O'CONNOR
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 KENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:DELMAR
Mailing Address - State:NY
Mailing Address - Zip Code:12054-3231
Mailing Address - Country:US
Mailing Address - Phone:518-439-0090
Mailing Address - Fax:518-439-0267
Practice Address - Street 1:413 KENWOOD AVE
Practice Address - Street 2:
Practice Address - City:DELMAR
Practice Address - State:NY
Practice Address - Zip Code:12054-3231
Practice Address - Country:US
Practice Address - Phone:518-439-0090
Practice Address - Fax:518-439-0267
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5421-1103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1328112OtherVALUE OPTIONS
NY01938247Medicaid
NYBB2446Medicare ID - Type Unspecified