Healthcare Provider Details

I. General information

NPI: 1073592457
Provider Name (Legal Business Name): ROBERT SCOTT ODEWALD PA-C, PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2006
Last Update Date: 10/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

332 NEWTOWN RD
VIRGINIA BEACH VA
23462-1793
US

IV. Provider business mailing address

PO BOX 758963
BALTIMORE MD
21275-8963
US

V. Phone/Fax

Practice location:
  • Phone: 757-473-8400
  • Fax: 757-473-0712
Mailing address:
  • Phone: 804-968-5700
  • Fax: 804-217-7991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: