Provider Demographics
NPI:1073656765
Name:DEAN, ODELL JOSEPH JR (MD)
Entity Type:Individual
Prefix:
First Name:ODELL
Middle Name:JOSEPH
Last Name:DEAN
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 1:130 DESIARD ST
Mailing Address - Street 2:SUITE 355
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-7319
Mailing Address - Country:US
Mailing Address - Phone:318-807-7875
Mailing Address - Fax:318-812-6603
Practice Address - Street 1:2516 BROADMOOR BLVD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-2988
Practice Address - Country:US
Practice Address - Phone:318-807-1390
Practice Address - Fax:318-807-1394
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.017252208800000X, 208800000X
MOR6P96208800000X
TN299643208800000X
MI4301062154208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1362352Medicaid
LA485810YJBUMedicare PIN
C67522Medicare UPIN
MS00112254Medicaid
TX0899197-02Medicaid
LA532656629Medicare PIN