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NPI Code Detail

MEDICARE: ODOM SPORTS MEDICINE, P.A.

MEDICARE: ODOM SPORTS MEDICINE, P.A.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207QS0010XSports Medicine (Family Medicine) Physician

General Provider Information

NPI Number : 1275557886
Entity Type Code : Organization
Provider Name (Legal Business Name) : ODOM SPORTS MEDICINE, P.A.
Provider Business Mailing Address
First Line : 10653 WAYZATA BLVD STE 200
Second Line :
City : MINNETONKA
State : MN
Zip : 55305-1543
Country : US
Telephone Number : 952-224-1919
Fax Number :
Provider Business Practice Location Address
First Line : 6545 FLYING CLOUD DR STE 201
Second Line :
City : EDEN PRAIRIE
State : MN
Zip : 55344-3356
Country : US
Telephone Number : 952-224-1919
Fax Number :
Authorized Official
Title or Position : PRESIDENT
Name : DR. JOHN H ODOM JR.
Credential : MD
Telephone Number : 952-224-1919
Provider Enumeration Date : 07/27/2006
Last Update Date : 04/23/2024

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