Provider Demographics
NPI:1720051162
Name:O'DONNELL, SUSAN (MD)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
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:PO BOX 366
Mailing Address - Street 2:
Mailing Address - City:STE GENEVIEVE
Mailing Address - State:MO
Mailing Address - Zip Code:63670-0366
Mailing Address - Country:US
Mailing Address - Phone:573-883-4477
Mailing Address - Fax:
Practice Address - Street 1:930 PARK DR
Practice Address - Street 2:
Practice Address - City:STE GENEVIEVE
Practice Address - State:MO
Practice Address - Zip Code:63670-1539
Practice Address - Country:US
Practice Address - Phone:573-883-7424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO103143207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO0450335OtherUHC
MO52598OtherGHP
MO193294OtherHEALTHLINK
MO52598OtherHEALTHCARE USA
MO20588OtherBCBS
MOE54304OtherMERCY HEALTH PLAN
MO999553OtherCOMMUNITY CARE PLUS
MO52598OtherHEALTHCARE USA