Provider Demographics
NPI:1508851361
Name:O'DONNELL, JOSEPH J (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:J
Last Name:O'DONNELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4150 NELSON RD
Mailing Address - Street 2:BUILDING G, SUITE 3
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-4148
Mailing Address - Country:US
Mailing Address - Phone:337-562-3732
Mailing Address - Fax:337-562-3699
Practice Address - Street 1:4150 NELSON RD
Practice Address - Street 2:BUILDING G, SUITE 3
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-4148
Practice Address - Country:US
Practice Address - Phone:337-562-3732
Practice Address - Fax:337-562-3699
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA08602R208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1910830Medicaid
LA4601931OtherAETNA
LAC19997Medicare UPIN
LA4601931OtherAETNA