Healthcare Provider Details

I. General information

NPI: 1699805960
Provider Name (Legal Business Name): AUBREY A. ODOM, O.D. P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 08/22/2020
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 P.O. BOX 862
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: DR. AUBREY ALAN ODOM
Title or Position: PRESIDENT
Credential: O.D.
Phone: 251-578-2922