Provider Demographics
NPI:1952426470
Name:LEO P O'CONNELL MD PC
Entity Type:Organization
Organization Name:LEO P O'CONNELL MD PC
Other - Org Name:BREAST DIAGNOSTIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL BILLING CLERK
Authorized Official - Prefix:MS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-595-8650
Mailing Address - Street 1:704 THIMBLE SHOALS BLVD
Mailing Address - Street 2:SUITE 600B
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-4544
Mailing Address - Country:US
Mailing Address - Phone:757-595-8650
Mailing Address - Fax:757-591-8651
Practice Address - Street 1:704 THIMBLE SHOALS BLVD
Practice Address - Street 2:SUITE 600B
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-4544
Practice Address - Country:US
Practice Address - Phone:757-595-8650
Practice Address - Fax:757-591-8651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101024069174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA630000723OtherMEDICARE RAILROAD
VA196140OtherANTHEM BCBS
VA7243481Medicaid
VA630000723OtherMEDICARE RAILROAD
VA196140OtherANTHEM BCBS