Healthcare Provider Details

I. General information

NPI: 1700175536
Provider Name (Legal Business Name): MICHAEL RYAN ODOM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: RYAN ODOM

II. Dates (important events)

Enumeration Date: 04/01/2011
Last Update Date: 02/16/2024
Certification Date: 02/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14402 E SPRAGUE AVE
SPOKANE VALLEY WA
99216-2167
US

IV. Provider business mailing address

1593 E POLSTON AVE
POST FALLS ID
83854-5326
US

V. Phone/Fax

Practice location:
  • Phone: 509-922-2625
  • Fax: 877-521-3642
Mailing address:
  • Phone: 208-262-2300
  • Fax: 208-262-2349

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2014-00995
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number48734
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number26919
License Number StateNE
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number16240
License Number StateNV
# 5
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM-15606
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: