Healthcare Provider Details

I. General information

NPI: 1700876554
Provider Name (Legal Business Name): CAROL M ODEGAARD M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 05/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

261 BROOKWOOD AVE
JACKSON GA
30233-1460
US

IV. Provider business mailing address

261 BROOKWOOD AVE
JACKSON GA
30233-1460
US

V. Phone/Fax

Practice location:
  • Phone: 678-752-0555
  • Fax: 678-752-0556
Mailing address:
  • Phone: 678-752-0555
  • Fax: 678-752-0556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number40495
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: