MEDICARE: JOHN W ODOM MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician	033661	GA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	CN8505	OTHER	GA	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1508866773
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN W ODOM MD

Provider Business Mailing Address
First Line	:	PO BOX 919
Second Line	:	594 S COLUMBIA DRIVE, STE 100
City	:	RINCON
State	:	GA
Zip	:	31326-0919
Country	:	US
Telephone Number	:	912-826-4057
Fax Number	:	912-826-2853

Provider Business Practice Location Address
First Line	:	594 S COLUMBIA AVE
Second Line	:	STE 100
City	:	RINCON
State	:	GA
Zip	:	31326-0919
Country	:	US
Telephone Number	:	912-826-4057
Fax Number	:	912-826-2853

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/28/2005
Last Update Date	:	02/04/2010

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Directions to “ JOHN W ODOM MD” Practice Location

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