MEDICARE: MRS. MARY E ODEGAARD MD

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	207Q00000X	Family Medicine Physician	81548	MA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	080078724	OTHER		RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	081548	OTHER		TUFTS
3	ODJ16519	OTHER	MA	BCBS
4	70989	OTHER	MA	HPHC
5	3552899	OTHER		CIGNA
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1942291349
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARY E ODEGAARD MD

Provider Business Mailing Address
First Line	:	111 GROSSMAN DR
Second Line	:	FAMILY MEDICINE
City	:	BRAINTREE
State	:	MA
Zip	:	02184-4997
Country	:	US
Telephone Number	:	781-849-2560
Fax Number	:	781-849-2529

Provider Business Practice Location Address
First Line	:	111 GROSSMAN DR
Second Line	:	FAMILY MEDICINE
City	:	BRAINTREE
State	:	MA
Zip	:	02184-4997
Country	:	US
Telephone Number	:	781-849-2560
Fax Number	:	781-849-2529

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

Provider Enumeration Date	:	11/03/2005
Last Update Date	:	10/23/2020

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Directions to “ MRS. MARY E ODEGAARD MD” Practice Location

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