Provider Demographics
NPI:1073514766
Name:ODOM, JOHN A JR (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:ODOM
Suffix:JR
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 1:10103 RIDGEGATE PKWY
Mailing Address - Street 2:
Mailing Address - City:LONE TREE
Mailing Address - State:CO
Mailing Address - Zip Code:80124-5525
Mailing Address - Country:US
Mailing Address - Phone:303-225-8120
Mailing Address - Fax:303-225-8130
Practice Address - Street 1:10103 RIDGEGATE PKWY
Practice Address - Street 2:
Practice Address - City:LONE TREE
Practice Address - State:CO
Practice Address - Zip Code:80124-5520
Practice Address - Country:US
Practice Address - Phone:303-225-8120
Practice Address - Fax:303-225-8130
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01158716Medicaid
CO34379OtherBSBC
COD22938Medicare UPIN
COCN7128Medicare PIN