Basic Information
| Provider Information | |||||||||
| NPI: | 1710047311 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | O'CONNELL | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1234 HUFFMAN MILL ROAD | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272158700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365381234 | ||||||||
| FaxNumber: | 3355846811 | ||||||||
| Practice Location | |||||||||
| Address1: | 1234 HUFFMAN MILL ROAD | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272158700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365381234 | ||||||||
| FaxNumber: | 3355846811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2006 | ||||||||
| LastUpdateDate: | 03/16/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | 9800991 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | 8911620 | 05 | NC | MEDICAID |