Healthcare Provider Details

I. General information

NPI: 1356871792
Provider Name (Legal Business Name): IAN ODIGIE DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2017
Last Update Date: 06/14/2023
Certification Date: 06/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

69 ALLEN ST STE 6
RUTLAND VT
05701-4564
US

IV. Provider business mailing address

69 ALLEN ST STE 1
RUTLAND VT
05701-4564
US

V. Phone/Fax

Practice location:
  • Phone: 802-773-8199
  • Fax: 802-773-7974
Mailing address:
  • Phone: 802-773-8199
  • Fax: 802-773-7974

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number056.0000197
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberSC006803
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: