Provider Demographics
NPI:1558363994
Name:O'DONNELL, DON ROBERT (OD)
Entity Type:Individual
Prefix:DR
First Name:DON
Middle Name:ROBERT
Last Name:O'DONNELL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5383 KODIAK RD
Mailing Address - Street 2:
Mailing Address - City:DIAMOND
Mailing Address - State:MO
Mailing Address - Zip Code:64840-6122
Mailing Address - Country:US
Mailing Address - Phone:417-782-1349
Mailing Address - Fax:
Practice Address - Street 1:825 S MAIDEN LN
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64801-3803
Practice Address - Country:US
Practice Address - Phone:417-781-6644
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOTO2300152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOT42759Medicare ID - Type Unspecified