Provider Demographics
NPI:1497754097
Name:ODONNELL, CARMEL M (MD)
Entity Type:Individual
Prefix:
First Name:CARMEL
Middle Name:M
Last Name:ODONNELL
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 1:410 N BROADWAY
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PITMAN
Mailing Address - State:NJ
Mailing Address - Zip Code:08071-1047
Mailing Address - Country:US
Mailing Address - Phone:856-589-3708
Mailing Address - Fax:856-589-2662
Practice Address - Street 1:410 N BROADWAY
Practice Address - Street 2:SUITE 1
Practice Address - City:PITMAN
Practice Address - State:NJ
Practice Address - Zip Code:08071-1047
Practice Address - Country:US
Practice Address - Phone:856-589-3708
Practice Address - Fax:856-589-2662
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB08097600207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0190292Medicaid
H01266Medicare UPIN
NJ0190292Medicaid