Provider Demographics
NPI:1962473108
Name:O'DONNELL, MARY (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:O'DONNELL
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 1:1000 ROUTE 9 N
Mailing Address - Street 2:SUITE 302
Mailing Address - City:WOODBRIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07095-1215
Mailing Address - Country:US
Mailing Address - Phone:732-634-0036
Mailing Address - Fax:732-855-9395
Practice Address - Street 1:1000 ROUTE 9 N
Practice Address - Street 2:SUITE 302
Practice Address - City:WOODBRIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07095-1215
Practice Address - Country:US
Practice Address - Phone:732-634-0036
Practice Address - Fax:732-855-9395
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA65838207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJK5409OtherHORIZON BLUE SHIELD
873097OtherAETNA
NJ8222100Medicaid
G61377Medicare UPIN
OD959486Medicare ID - Type Unspecified