Provider Demographics
NPI:1043279375
Name:ODELL, JAY MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:MICHAEL
Last Name:ODELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3941
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-3941
Mailing Address - Country:US
Mailing Address - Phone:360-459-7770
Mailing Address - Fax:360-459-4361
Practice Address - Street 1:3900 CAPITAL MALL DRIVE SW
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502
Practice Address - Country:US
Practice Address - Phone:360-754-5858
Practice Address - Fax:360-956-2574
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00018566207ZP0102X, 207ZP0213X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZP0213XAllopathic & Osteopathic PhysiciansPathologyPediatric Pathology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA203964OtherLABOR & INDUSTRIES
WA8000994Medicaid
WA8000994Medicaid
E37054Medicare UPIN
WAG8855828Medicare PIN