Healthcare Provider Details

I. General information

NPI: 1184281602
Provider Name (Legal Business Name): JACOB COLIN O'DELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2019
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 S EAGLE RD STE 1241
MERIDIAN ID
83642-6355
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-381-6930
  • Fax:
Mailing address:
  • Phone: 208-381-8866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number8181303
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number1184281602
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: