Healthcare Provider Details

I. General information

NPI: 1851949416
Provider Name (Legal Business Name): MADISON DAWN ODOM PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2019
Last Update Date: 07/30/2025
Certification Date: 07/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2985 MACK DOBBS RD NW
KENNESAW GA
30152-2641
US

IV. Provider business mailing address

3333 RIVERWOOD PKWY SE STE 250
ATLANTA GA
30339-3304
US

V. Phone/Fax

Practice location:
  • Phone: 770-268-4011
  • Fax: 470-251-6052
Mailing address:
  • Phone: 770-914-0116
  • Fax: 770-955-4278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10775
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: