Provider Demographics
NPI:1760485510
Name:O'DONNELL, TIMOTHY PATRICK (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:PATRICK
Last Name:O'DONNELL
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 1:3600 KOLBE RD STE 205
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44053-1677
Mailing Address - Country:US
Mailing Address - Phone:440-960-6431
Mailing Address - Fax:440-960-6435
Practice Address - Street 1:3600 KOLBE RD STE 205
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053
Practice Address - Country:US
Practice Address - Phone:440-960-6431
Practice Address - Fax:440-960-6435
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35082804208600000X, 208C00000X, 208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2435958Medicaid
OH2435958Medicaid
PA126073PJGMedicare PIN