Provider Demographics
NPI:1700859295
Name:ODONOVAN, JOHN CROSSAN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:CROSSAN
Last Name:ODONOVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2112 DUNDALK AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21222
Mailing Address - Country:US
Mailing Address - Phone:410-284-1133
Mailing Address - Fax:410-284-8371
Practice Address - Street 1:2112 DUNDALK AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21222-3714
Practice Address - Country:US
Practice Address - Phone:410-284-1133
Practice Address - Fax:410-284-8371
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD07632208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD022731500Medicaid
B70791Medicare UPIN