Provider Demographics
NPI:1679513758
Name:O'DONNELL, TIMOTHY R (DO)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:R
Last Name:O'DONNELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 E STEWART ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45409-2624
Mailing Address - Country:US
Mailing Address - Phone:937-208-9010
Mailing Address - Fax:937-208-9020
Practice Address - Street 1:51 E STEWART ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-2624
Practice Address - Country:US
Practice Address - Phone:937-208-9010
Practice Address - Fax:937-208-9020
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-00-3716-O207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0664124Medicaid
OH0664124Medicaid
OH0598737Medicare PIN
OH0598736Medicare PIN