Healthcare Provider Details

I. General information

NPI: 1669376372
Provider Name (Legal Business Name): TAWNY ODOM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2026
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 KENYON RD
FORT DODGE IA
50501-5776
US

IV. Provider business mailing address

1829 6TH AVE N
FORT DODGE IA
50501-3505
US

V. Phone/Fax

Practice location:
  • Phone: 515-574-6800
  • Fax:
Mailing address:
  • Phone: 515-574-6800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number158463
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: