Healthcare Provider Details

I. General information

NPI: 1770043739
Provider Name (Legal Business Name): ALEXANDRA ODOM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2019
Last Update Date: 10/29/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5656 S CEDAR ST
LANSING MI
48911-3894
US

IV. Provider business mailing address

145 GREAT RD STE 6 FARM HILL PLAZA #1054
ACTON MA
01720
US

V. Phone/Fax

Practice location:
  • Phone: 517-267-3925
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0101273427
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA186889
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: