Healthcare Provider Details

I. General information

NPI: 1275557886
Provider Name (Legal Business Name): ODOM SPORTS MEDICINE, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6545 FLYING CLOUD DR STE 201
EDEN PRAIRIE MN
55344-3356
US

IV. Provider business mailing address

6545 FLYING CLOUD DR STE 201
EDEN PRAIRIE MN
55344-3356
US

V. Phone/Fax

Practice location:
  • Phone: 952-224-1919
  • Fax: 612-999-1943
Mailing address:
  • Phone: 952-224-1919
  • Fax: 612-999-1943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: CAITLYN LARSEN
Title or Position: BILLING SUPERVISOR
Credential:
Phone: 612-619-8674