Healthcare Provider Details

I. General information

NPI: 1508866773
Provider Name (Legal Business Name): JOHN W ODOM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 02/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

594 S COLUMBIA AVE STE 100
RINCON GA
31326-0919
US

IV. Provider business mailing address

PO BOX 919 594 S COLUMBIA DRIVE, STE 100
RINCON GA
31326-0919
US

V. Phone/Fax

Practice location:
  • Phone: 912-826-4057
  • Fax: 912-826-2853
Mailing address:
  • Phone: 912-826-4057
  • Fax: 912-826-2853

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number033661
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: