Provider Demographics
NPI:1093197980
Name:ODOM, MICHAEL STEPHEN (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:STEPHEN
Last Name:ODOM
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 262
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29622-0262
Mailing Address - Country:US
Mailing Address - Phone:864-512-2830
Mailing Address - Fax:864-512-2379
Practice Address - Street 1:12016 N RADIO STATION RD
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29678-1143
Practice Address - Country:US
Practice Address - Phone:864-882-6141
Practice Address - Fax:864-882-6680
Is Sole Proprietor?:No
Enumeration Date:2015-06-26
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC38156207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine