Healthcare Provider Details

I. General information

NPI: 1609868058
Provider Name (Legal Business Name): ODELL P. STILL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2005
Last Update Date: 04/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 W DYKES ST
COCHRAN GA
31014
US

IV. Provider business mailing address

PO BOX 1297
HAWKINSVILLE GA
31036-7297
US

V. Phone/Fax

Practice location:
  • Phone: 478-934-0030
  • Fax: 478-783-3730
Mailing address:
  • Phone: 478-783-0299
  • Fax: 478-783-3730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number37085
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: