MEDICARE: RAANAN SUSANNE ODOM M.D.

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
1	208000000X	Pediatrics Physician	A97244	CA
2	208000000X	Pediatrics Physician	MD60142080	WA

General Provider Information

NPI Number	:	1821263336
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RAANAN SUSANNE ODOM M.D.

Provider Business Mailing Address
First Line	:	PO BOX 25608
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84125-0608
Country	:	US
Telephone Number	:	206-320-4476
Fax Number	:	206-233-7489

Provider Business Practice Location Address
First Line	:	3400 CALIFORNIA AVE SW STE 200
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98116-3307
Country	:	US
Telephone Number	:	206-320-5780
Fax Number	:	206-320-5794

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/25/2008
Last Update Date	:	10/08/2020

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