Provider Demographics
NPI:1114294972
Name:CAROL M. ODEGAARD, MD, PC
Entity Type:Organization
Organization Name:CAROL M. ODEGAARD, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:M
Authorized Official - Last Name:ODEGAARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-752-0555
Mailing Address - Street 1:261 BROOKWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:GA
Mailing Address - Zip Code:30233-1460
Mailing Address - Country:US
Mailing Address - Phone:678-752-0555
Mailing Address - Fax:678-752-0556
Practice Address - Street 1:261 BROOKWOOD AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:GA
Practice Address - Zip Code:30233-1460
Practice Address - Country:US
Practice Address - Phone:678-752-0555
Practice Address - Fax:678-752-0556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-22
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA040495207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003122938AOtherMEDICAID FACILITY
GA003122938AOtherMEDICAID FACILITY