Provider Demographics
NPI:1811923683
Name:O'LEARY, MICHAEL J (DC, CCS P)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:O'LEARY
Suffix:
Gender:M
Credentials:DC, CCS P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:395 BAY RD
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-1405
Mailing Address - Country:US
Mailing Address - Phone:518-793-1205
Mailing Address - Fax:518-793-1515
Practice Address - Street 1:395 BAY RD
Practice Address - Street 2:
Practice Address - City:QUEENSBURY
Practice Address - State:NY
Practice Address - Zip Code:12804-1405
Practice Address - Country:US
Practice Address - Phone:518-793-1205
Practice Address - Fax:518-793-1515
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-24
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX007268-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBA0323Medicare PIN