Provider Demographics
NPI:1649363573
Name:W C ODONNELL JR MD PA
Entity type:Organization
Organization Name:W C ODONNELL JR MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:ODONNELL
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:830-257-5665
Mailing Address - Street 1:708 HILL COUNTRY DR
Mailing Address - Street 2:BUILDING 300A
Mailing Address - City:KERRVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78028-6079
Mailing Address - Country:US
Mailing Address - Phone:830-257-5665
Mailing Address - Fax:830-896-4434
Practice Address - Street 1:708 HILL COUNTRY DR
Practice Address - Street 2:BUILDING 300A
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028-6079
Practice Address - Country:US
Practice Address - Phone:830-257-5665
Practice Address - Fax:830-896-4434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE3389207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0018QJOtherBLUE CROSS BLUE SHIELD
TX170958601Medicaid
TXA007OtherHOH CARDIAC REHAB TRICARE
TXC19996Medicare UPIN
00975XMedicare PIN
TX080111585Medicare PIN
TX170958601Medicaid
TXA007OtherHOH CARDIAC REHAB TRICARE