Healthcare Provider Details

I. General information

NPI: 1093815474
Provider Name (Legal Business Name): CECIL DOUGLAS ODOM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 10/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 RIVER OAKS DRIVE, STE 310
JACKSON MS
39232
US

IV. Provider business mailing address

1020 RIVER OAKS DRIVE, STE 310
JACKSON MS
39232
US

V. Phone/Fax

Practice location:
  • Phone: 601-932-5006
  • Fax: 601-932-4548
Mailing address:
  • Phone: 601-932-5006
  • Fax: 601-932-4548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number05821
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: