Provider Demographics
NPI:1174038046
Name:UPSHAW, ODELL JR
Entity Type:Individual
Prefix:
First Name:ODELL
Middle Name:
Last Name:UPSHAW
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 MEIGS ST APT 1A
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14607-2054
Mailing Address - Country:US
Mailing Address - Phone:585-448-8539
Mailing Address - Fax:
Practice Address - Street 1:85 MEIGS ST APT 1A
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14607-2054
Practice Address - Country:US
Practice Address - Phone:585-448-8539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-13
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY327329-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse