Healthcare Provider Details

I. General information

NPI: 1154614816
Provider Name (Legal Business Name): SHYAM SUNDHAR ODETI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2011
Last Update Date: 09/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16000 JOHNSTON MEMORIAL DR FOURTH FLOOR
ABINGDON VA
24211-7659
US

IV. Provider business mailing address

16000 JOHNSTON MEMORIAL DR FOURTH FLOOR
ABINGDON VA
24211-7659
US

V. Phone/Fax

Practice location:
  • Phone: 276-258-4050
  • Fax: 276-258-4056
Mailing address:
  • Phone: 276-258-4050
  • Fax: 276-258-4056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101256639
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: