Provider Demographics
NPI:1770502809
Name:O'DONNELL, TIMOTHY (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
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 1:322 EAST CECIL AVENUE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:NORTH EAST
Mailing Address - State:MD
Mailing Address - Zip Code:21901
Mailing Address - Country:US
Mailing Address - Phone:410-287-3727
Mailing Address - Fax:410-287-2819
Practice Address - Street 1:SUITE 32 PEOPLES PLAZA
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19702
Practice Address - Country:US
Practice Address - Phone:302-834-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0033510207R00000X
DECI0003058207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000229701Medicaid
DE00G00N30Medicare ID - Type Unspecified
C48788Medicare UPIN
DE0000229701Medicaid