Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | DO2188 | AL |
NPI | 1003357195 |
---|---|
Provider Name | Kealan O'neill I |
First Address | Madison, AL 35758-1890 |
Second Address | Madison, AL 35758-1890 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 09/03/2017 |
Last Update Date | 13/08/2020 |