Healthcare Provider Details

I. General information

NPI: 1477050573
Provider Name (Legal Business Name): TRAVIS LEE ODOM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2018
Last Update Date: 09/24/2024
Certification Date: 09/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 11049
NORFOLK VA
23517-0049
US

IV. Provider business mailing address

2100 STANTONSBURG RD
GREENVILLE NC
27834-2818
US

V. Phone/Fax

Practice location:
  • Phone: 757-668-7871
  • Fax: 757-668-8658
Mailing address:
  • Phone: 252-744-2335
  • Fax: 252-744-3811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number0101281971
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: