Healthcare Provider Details

I. General information

NPI: 1740625870
Provider Name (Legal Business Name): ODOM SPORTS MEDICINE, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2013
Last Update Date: 05/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 S CHERRY ST
WACONIA MN
55387-4515
US

IV. Provider business mailing address

10500 WAYZATA BLVD
MINNETONKA MN
55305-1511
US

V. Phone/Fax

Practice location:
  • Phone: 952-856-4722
  • Fax:
Mailing address:
  • Phone: 952-224-1919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN H.L. ODOM JR.
Title or Position: PRESIDENT
Credential: M.D.
Phone: 952-224-1919