Healthcare Provider Details

I. General information

NPI: 1497458095
Provider Name (Legal Business Name): MATTHEW TYLER ODOM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2023
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 MEDICAL PARK BLVD
BRISTOL TN
37620-7343
US

IV. Provider business mailing address

100 VERMONT AVE
OAK RIDGE TN
37830-6471
US

V. Phone/Fax

Practice location:
  • Phone: 423-989-4050
  • Fax: 423-990-3044
Mailing address:
  • Phone: 865-482-1777
  • Fax: 865-374-2117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number76768
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: