Provider Demographics
NPI:1881972909
Name:O'DONNELL, KIRK N (MD)
Entity type:Individual
Prefix:DR
First Name:KIRK
Middle Name:N
Last Name:O'DONNELL
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2943 PARKWAY BLVD
Mailing Address - Street 2:PMB 80
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84119
Mailing Address - Country:US
Mailing Address - Phone:314-452-3780
Mailing Address - Fax:731-201-5047
Practice Address - Street 1:2943 PARKWAY BLVD
Practice Address - Street 2:PMB 80
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84119
Practice Address - Country:US
Practice Address - Phone:314-452-3780
Practice Address - Fax:731-201-5047
Is Sole Proprietor?:No
Enumeration Date:2011-07-22
Last Update Date:2023-08-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
UT12060095-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN080023025Medicare PIN