Provider Demographics
NPI:1528011830
Name:O'CONNOR, JEFFREY LAWRENCE (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:LAWRENCE
Last Name:O'CONNOR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1795 STANLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-1953
Mailing Address - Country:US
Mailing Address - Phone:248-569-4898
Mailing Address - Fax:
Practice Address - Street 1:22250 PROVIDENCE DR
Practice Address - Street 2:SUITE 203
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4825
Practice Address - Country:US
Practice Address - Phone:248-569-0155
Practice Address - Fax:248-569-5226
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301085172208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4781079Medicaid
MI4781079Medicaid
MII29433Medicare UPIN