Provider Demographics
NPI:1023057734
Name:O'DONNELL, DENNIS MARTIN (MD)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:MARTIN
Last Name:O'DONNELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 19368
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27619-9368
Mailing Address - Country:US
Mailing Address - Phone:919-787-8221
Mailing Address - Fax:919-789-4461
Practice Address - Street 1:3949 BROWNING PL
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-6504
Practice Address - Country:US
Practice Address - Phone:919-787-8221
Practice Address - Fax:919-789-4461
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC354522085N0904X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC16-54635OtherUNITED HEALTHCARE
NC16-54634OtherUNITED HEALTHCARE
NC8963758Medicaid
VA7208057OtherVIRGINIA MEDICAID
NC63189OtherMEDCOST
NC63758OtherBLUECROSS BLUESHIELD
NC16-54636OtherUNITED HEALTHCARE
NC63128OtherMEDCOST
NC63161OtherMEDCOST
NC63189OtherMEDCOST
D61807Medicare UPIN
NC16-54635OtherUNITED HEALTHCARE
NC16-54636OtherUNITED HEALTHCARE