Provider Demographics
NPI:1528017878
Name:O'CONNELL, CHRISTOPHER M (DO)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:M
Last Name:O'CONNELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15420 19 MILE RD
Mailing Address - Street 2:STE. 200
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-6339
Mailing Address - Country:US
Mailing Address - Phone:586-649-6104
Mailing Address - Fax:586-263-0250
Practice Address - Street 1:15420 19 MILE RD
Practice Address - Street 2:STE. 200
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-6339
Practice Address - Country:US
Practice Address - Phone:586-649-6104
Practice Address - Fax:586-263-0250
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102206803207Q00000X
MI5101014284207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4412861Medicaid
MI4412870Medicaid
MI4648909Medicaid
MI4412880Medicaid
MI4412870Medicaid
MI0E06239083Medicare ID - Type Unspecified