Healthcare Provider Details

I. General information

NPI: 1457309130
Provider Name (Legal Business Name): LANNY ODIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 06/18/2020
Certification Date: 06/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 N CHENEY ST
TAYLORVILLE IL
62568-1139
US

IV. Provider business mailing address

500 N CHENEY ST
TAYLORVILLE IL
62568-1139
US

V. Phone/Fax

Practice location:
  • Phone: 217-777-2020
  • Fax: 217-777-2023
Mailing address:
  • Phone: 217-777-2020
  • Fax: 217-777-2023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number036077639
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: