Healthcare Provider Details

I. General information

NPI: 1972558062
Provider Name (Legal Business Name): THOMAS B ODEGARD AU.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 VETERANS DR 2 S100
MINNEAPOLIS MN
55417-2309
US

IV. Provider business mailing address

1 VETERANS DR 2 S100
MINNEAPOLIS MN
55417-2309
US

V. Phone/Fax

Practice location:
  • Phone: 612-467-4086
  • Fax: 612-725-2245
Mailing address:
  • Phone: 612-467-4086
  • Fax: 612-725-2245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231HA2400X
TaxonomyAssistive Technology Practitioner Audiologist
License Number1020
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: