Provider Demographics
NPI:1093705832
Name:ODIET, JEFF (MD)
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:
Last Name:ODIET
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 1:2 ESSEX CENTER DR
Mailing Address - Street 2:
Mailing Address - City:PEABODY
Mailing Address - State:MA
Mailing Address - Zip Code:01960-2902
Mailing Address - Country:US
Mailing Address - Phone:978-532-2800
Mailing Address - Fax:978-977-4491
Practice Address - Street 1:2 ESSEX CENTER DR
Practice Address - Street 2:
Practice Address - City:PEABODY
Practice Address - State:MA
Practice Address - Zip Code:01960-2902
Practice Address - Country:US
Practice Address - Phone:978-532-2800
Practice Address - Fax:978-977-4491
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2011-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA160253207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3194671Medicaid
MAA29615Medicare PIN
G93730Medicare UPIN