Provider Demographics
NPI:1619997772
Name:O'DONNELL, KELLY (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:O'DONNELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:166 DEFENSE HWY STE 101
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-8921
Mailing Address - Country:US
Mailing Address - Phone:410-224-3390
Mailing Address - Fax:410-224-3370
Practice Address - Street 1:166 DEFENSE HWY
Practice Address - Street 2:SUITE 101
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-8919
Practice Address - Country:US
Practice Address - Phone:410-224-3390
Practice Address - Fax:410-224-3370
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD32654207L00000X
MDD0042645202K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes202K00000XAllopathic & Osteopathic PhysiciansPhlebology
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC027449600Medicaid
VA5711193OtherVIRGINIA MEDICAID
DC566739OtherNCPPO
DC7016224OtherAETNA NON HMO
DC212103OtherKAISER
DC3058246001OtherCIGNA HMO
MD234501301Medicaid
DC0113OtherCAREFIRST BCBS
DC2561122OtherAETNA HMO
VA441777OtherANTHEM BCBS
DC7016224OtherAETNA NON HMO
VA5711193OtherVIRGINIA MEDICAID
DC3058246001OtherCIGNA HMO