Provider Demographics
NPI:1003220138
Name:O'DELL, JUSTINE J (OD)
Entity Type:Individual
Prefix:DR
First Name:JUSTINE
Middle Name:J
Last Name:O'DELL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:4614 OLD SPARTANBURG RD
Mailing Address - Street 2:APT 34
Mailing Address - City:TAYLORS
Mailing Address - State:SC
Mailing Address - Zip Code:29687-4149
Mailing Address - Country:US
Mailing Address - Phone:419-450-2606
Mailing Address - Fax:
Practice Address - Street 1:227 E BLACKSTOCK RD
Practice Address - Street 2:SUITE 200
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29301-2631
Practice Address - Country:US
Practice Address - Phone:864-576-0564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-17
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC1823152W00000X, 152WC0802X, 152WL0500X, 152WP0200X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy