Provider Demographics
NPI:1134283237
Name:ODIN, ROSALIND (MD)
Entity Type:Individual
Prefix:DR
First Name:ROSALIND
Middle Name:
Last Name:ODIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6700 KIRKVILLE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-9305
Mailing Address - Country:US
Mailing Address - Phone:315-463-2013
Mailing Address - Fax:315-463-2019
Practice Address - Street 1:6700 KIRKVILLE RD
Practice Address - Street 2:SUITE A
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-9305
Practice Address - Country:US
Practice Address - Phone:315-463-2013
Practice Address - Fax:315-463-2019
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY195023208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01575144Medicaid