Provider Demographics
NPI:1508972233
Name:O'HARA, PATRICK
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:
Last Name:O'HARA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICKTOWN
Mailing Address - State:MO
Mailing Address - Zip Code:63645-1111
Mailing Address - Country:US
Mailing Address - Phone:573-783-3341
Mailing Address - Fax:573-783-1096
Practice Address - Street 1:611 W MAIN ST
Practice Address - Street 2:
Practice Address - City:FREDERICKTOWN
Practice Address - State:MO
Practice Address - Zip Code:63645-1111
Practice Address - Country:US
Practice Address - Phone:573-783-3341
Practice Address - Fax:573-783-1096
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO110421207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO204647903Medicaid
G92165Medicare UPIN
MO204647903Medicaid