Provider Demographics
NPI:1619384591
Name:O'DONOGHUE, PATRICK (LMT)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:
Last Name:O'DONOGHUE
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 2ND ST SW
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-2903
Mailing Address - Country:US
Mailing Address - Phone:863-521-7829
Mailing Address - Fax:
Practice Address - Street 1:170 2ND ST SW
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-2903
Practice Address - Country:US
Practice Address - Phone:863-521-7829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-12
Last Update Date:2014-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA46278172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist