Healthcare Provider Details

I. General information

NPI: 1790246676
Provider Name (Legal Business Name): BILLIE SUZANNE ODOM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2019
Last Update Date: 08/03/2023
Certification Date: 08/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

583 S CLARIZZ BLVD
BLOOMINGTON IN
47401-5515
US

IV. Provider business mailing address

250 N SHADELAND AVE
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 812-676-4460
  • Fax: 812-355-4092
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number01090478A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: