Healthcare Provider Details

I. General information

NPI: 1972997286
Provider Name (Legal Business Name): LANNY S ODIN MD SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2015
Last Update Date: 04/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 N CHENEY ST
TAYLORVILLE IL
62568-1139
US

IV. Provider business mailing address

PO BOX 110
TAYLORVILLE IL
62568-0110
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 TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: LANNY SCOTT ODIN
Title or Position: PRESIDENT
Credential: M. D.
Phone: 217-777-2020