Provider Demographics
NPI:1568466555
Name:O'CONNOR, EDWARD J (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:J
Last Name:O'CONNOR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2811 WILSHIRE BLVD
Mailing Address - Street 2:STE 790
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-4805
Mailing Address - Country:US
Mailing Address - Phone:310-829-5968
Mailing Address - Fax:310-453-3685
Practice Address - Street 1:2811 WILSHIRE BLVD
Practice Address - Street 2:STE 790
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-4805
Practice Address - Country:US
Practice Address - Phone:310-829-5968
Practice Address - Fax:310-453-3685
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-08
Last Update Date:2015-04-23
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
CAA244002084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA24400Medicare ID - Type UnspecifiedLICENSE #