Provider Demographics
NPI:1700062981
Name:SEAN C ODONNELL
Entity Type:Organization
Organization Name:SEAN C ODONNELL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:ODONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-473-6171
Mailing Address - Street 1:629 N NEVADA AVE
Mailing Address - Street 2:SUITE110
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-1040
Mailing Address - Country:US
Mailing Address - Phone:719-473-6171
Mailing Address - Fax:719-473-0740
Practice Address - Street 1:629 N NEVADA AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-1040
Practice Address - Country:US
Practice Address - Phone:719-473-6171
Practice Address - Fax:719-473-0740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-17
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO25481305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01254812Medicaid
COD24639Medicare UPIN
CO152008Medicare PIN