Healthcare Provider Details

I. General information

NPI: 1386623908
Provider Name (Legal Business Name): KIMBERLY P ODOM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2006
Last Update Date: 03/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 SO. MYRTLE AVENUE
CLEARWATER FL
33756
US

IV. Provider business mailing address

613 SO. MYRTLE AVENUE
CLEARWATER FL
33756
US

V. Phone/Fax

Practice location:
  • Phone: 727-447-6458
  • Fax: 727-461-5211
Mailing address:
  • Phone: 727-442-8589
  • Fax: 727-461-5211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME83246
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: