Healthcare Provider Details

I. General information

NPI: 1457627531
Provider Name (Legal Business Name): IAN DOUGLAS ODELL M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2012
Last Update Date: 05/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 CEDAR ST BLDG LMP ROOM 5040
NEW HAVEN CT
06510-3206
US

IV. Provider business mailing address

15 YORK ST ROOM 5040
NEW HAVEN CT
06510-3221
US

V. Phone/Fax

Practice location:
  • Phone: 203-785-4092
  • Fax:
Mailing address:
  • Phone: 203-785-4092
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number55057
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: