Provider Demographics
NPI:1023311024
Name:O'DONNELL, MARK EDWARD (IDC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:EDWARD
Last Name:O'DONNELL
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 THRESHER AVE
Mailing Address - Street 2:
Mailing Address - City:SLIVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98315
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2100 THRESHER AVE
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98315-2103
Practice Address - Country:US
Practice Address - Phone:360-396-4206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-13
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider