Provider Demographics
NPI:1639141807
Name:O'CONNELL, KEVIN M (DO)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
Last Name:O'CONNELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7974 UW HEALTH COURT
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-5531
Mailing Address - Country:US
Mailing Address - Phone:608-267-6000
Mailing Address - Fax:608-826-2710
Practice Address - Street 1:7102 MINERAL POINT ROAD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53717-1706
Practice Address - Country:US
Practice Address - Phone:608-828-7603
Practice Address - Fax:608-826-2710
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI24735207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31574000Medicaid
E87795Medicare UPIN
WI31574000Medicaid