Provider Demographics
NPI:1013047190
Name:O'DONNELL, PATRICIA M (DPM)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:M
Last Name:O'DONNELL
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:885 ROOSEVELT RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-6141
Mailing Address - Country:US
Mailing Address - Phone:630-225-2663
Mailing Address - Fax:630-225-2399
Practice Address - Street 1:885 ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-6141
Practice Address - Country:US
Practice Address - Phone:630-225-2663
Practice Address - Fax:630-225-2399
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0016004785213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL206147OtherMEDICARE PTAN (GROUP)
IL016004785OtherMEDICAID
ILF400181111OtherMEDICARE PTAN (INDIVIDUAL)
ILU62306Medicare UPIN