Provider Demographics
NPI:1093747909
Name:ODOM, RICHARD B (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:B
Last Name:ODOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:461 SEVENTH ST. WEST,
Mailing Address - Street 2:SUITE 3
Mailing Address - City:SONOMA
Mailing Address - State:CA
Mailing Address - Zip Code:95476
Mailing Address - Country:US
Mailing Address - Phone:707-938-1423
Mailing Address - Fax:707-938-2654
Practice Address - Street 1:461 7TH ST W
Practice Address - Street 2:SUITE 3
Practice Address - City:SONOMA
Practice Address - State:CA
Practice Address - Zip Code:95476-5976
Practice Address - Country:US
Practice Address - Phone:707-938-1423
Practice Address - Fax:707-938-2654
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAC41605207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA37641Medicare UPIN
CA00G416051Medicare ID - Type Unspecified