Provider Demographics
NPI:1942264262
Name:OCONNELL, MARY (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:OCONNELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12900 NE 180 STREET
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98011
Mailing Address - Country:US
Mailing Address - Phone:425-398-9355
Mailing Address - Fax:425-486-5913
Practice Address - Street 1:12900 NE 180 STREET
Practice Address - Street 2:SUITE 100
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011
Practice Address - Country:US
Practice Address - Phone:425-398-9355
Practice Address - Fax:425-486-5913
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00026764207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1072487Medicaid
E72331Medicare UPIN
109751Medicare ID - Type Unspecified