Provider Demographics
NPI:1841239050
Name:O'DONNELL, TIMOTHY (DO)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:
Last Name:O'DONNELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 BEAVERBROOK RD STE 301
Mailing Address - Street 2:
Mailing Address - City:LINCOLN PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07035-1440
Mailing Address - Country:US
Mailing Address - Phone:973-694-1300
Mailing Address - Fax:973-694-1399
Practice Address - Street 1:63 BEAVERBROOK RD STE 301
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:NJ
Practice Address - Zip Code:07035-1440
Practice Address - Country:US
Practice Address - Phone:973-694-1300
Practice Address - Fax:973-694-1399
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-05
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB04853800207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ538110Medicaid
NJF27383Medicare UPIN