Provider Demographics
NPI:1588615124
Name:O'DELL, KEVIN BRUCE (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:BRUCE
Last Name:O'DELL
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 1:1200 STILL FOREST CT
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28056-6607
Mailing Address - Country:US
Mailing Address - Phone:704-473-3507
Mailing Address - Fax:
Practice Address - Street 1:566 RUIN CREEK RD
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NC
Practice Address - Zip Code:27536-2927
Practice Address - Country:US
Practice Address - Phone:252-436-1164
Practice Address - Fax:252-433-0280
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC000039312174400000X
NC39312207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC63666OtherBSNC
NC8963666Medicaid
NCE30853Medicare UPIN
NC8963666Medicaid