Provider Demographics
NPI:1639271513
Name:DWIGHT O'DELL, M.D., LTD.
Entity Type:Organization
Organization Name:DWIGHT O'DELL, M.D., LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DWIGHT
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:O'DELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-233-5998
Mailing Address - Street 1:4550 MEMORIAL DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-5359
Mailing Address - Country:US
Mailing Address - Phone:618-233-5998
Mailing Address - Fax:618-233-6001
Practice Address - Street 1:4550 MEMORIAL DR
Practice Address - Street 2:SUITE 200
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5359
Practice Address - Country:US
Practice Address - Phone:618-233-5998
Practice Address - Fax:618-233-6001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-02
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL214216Medicare PIN
ILC46175Medicare UPIN