Healthcare Provider Details

I. General information

NPI: 1295803195
Provider Name (Legal Business Name): AUBREY ALAN ODOM O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 S MAIN ST
EVERGREEN AL
36401-3320
US

IV. Provider business mailing address

109 S MAIN ST
EVERGREEN AL
36401-3320
US

V. Phone/Fax

Practice location:
  • Phone: 251-578-2922
  • Fax: 251-578-2952
Mailing address:
  • Phone: 251-578-2922
  • Fax: 251-578-2952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberS-860-TA-413
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: