Healthcare Provider Details

I. General information

NPI: 1699569269
Provider Name (Legal Business Name): SASHA M ODOM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2025
Last Update Date: 05/25/2025
Certification Date: 05/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2426 55TH PL
INDIANAPOLIS IN
46220-3502
US

IV. Provider business mailing address

2426 55TH PL
INDIANAPOLIS IN
46220-3502
US

V. Phone/Fax

Practice location:
  • Phone: 463-221-2605
  • Fax: 463-221-2507
Mailing address:
  • Phone: 463-221-2605
  • Fax: 463-221-2507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code247ZC0005X
TaxonomyClinical Laboratory Director (Non-physician)
License Number
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: