Provider Demographics
NPI:1912920406
Name:O'CONNOR, MARY TERESA (MD)
Entity Type:Individual
Prefix:MISS
First Name:MARY
Middle Name:TERESA
Last Name:O'CONNOR
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 1:14 MEADOWBROOK CT
Mailing Address - Street 2:
Mailing Address - City:SUMMIT
Mailing Address - State:NJ
Mailing Address - Zip Code:07901-2317
Mailing Address - Country:US
Mailing Address - Phone:908-273-7983
Mailing Address - Fax:
Practice Address - Street 1:25 S UNION AVE
Practice Address - Street 2:
Practice Address - City:CRANFORD
Practice Address - State:NJ
Practice Address - Zip Code:07016-2843
Practice Address - Country:US
Practice Address - Phone:908-709-1323
Practice Address - Fax:908-709-1329
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04406400261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center