Provider Demographics
NPI:1679598882
Name:O'DONNELL, DEREK WILLIAM (OD)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:WILLIAM
Last Name:O'DONNELL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 BRANDT DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CRANBERRY TWP
Mailing Address - State:PA
Mailing Address - Zip Code:16066-6437
Mailing Address - Country:US
Mailing Address - Phone:724-772-5420
Mailing Address - Fax:
Practice Address - Street 1:105 BRANDT DR
Practice Address - Street 2:SUITE 201
Practice Address - City:CRANBERRY TWP
Practice Address - State:PA
Practice Address - Zip Code:16066-6437
Practice Address - Country:US
Practice Address - Phone:724-772-5420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001827152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA130144Medicare PIN