Healthcare Provider Details

I. General information

NPI: 1215949276
Provider Name (Legal Business Name): AUDREY RAGAN ODOM JOHN MD PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AUDREY RAGAN ODOM MD

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 CIVIC CENTER BLVD
PHILADELPHIA PA
19104-4319
US

IV. Provider business mailing address

734 SCHUYLKILL AVE
PHILADELPHIA PA
19146-2300
US

V. Phone/Fax

Practice location:
  • Phone: 314-616-5691
  • Fax:
Mailing address:
  • Phone: 314-616-5691
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD468283
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code2080P0208X
TaxonomyPediatric Infectious Diseases Physician
License NumberMD468283
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: