Provider Demographics
NPI:1073609467
Name:ODOM, PAUL LEROY (MD)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:LEROY
Last Name:ODOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 725
Mailing Address - Street 2:604 SOUTH MAIN STREET
Mailing Address - City:WATER VALLEY
Mailing Address - State:MS
Mailing Address - Zip Code:38965
Mailing Address - Country:US
Mailing Address - Phone:662-473-1311
Mailing Address - Fax:662-473-2489
Practice Address - Street 1:604 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:WATER VALLEY
Practice Address - State:MS
Practice Address - Zip Code:38965
Practice Address - Country:US
Practice Address - Phone:662-473-1311
Practice Address - Fax:662-473-2489
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSMS04851207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00011845Medicaid
081945456Medicare ID - Type Unspecified
MS00011845Medicaid