Provider Demographics
NPI:1174675631
Name:ODRICH, MARC G (MD)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:G
Last Name:ODRICH
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:PO BOX 9007
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22906-9007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1300 JEFFERSON PARK AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903-3363
Practice Address - Country:US
Practice Address - Phone:434-924-5485
Practice Address - Fax:434-244-9436
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY163491207W00000X
VA0101261433207WX0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0120XAllopathic & Osteopathic PhysiciansOphthalmologyCornea and External Diseases SpecialistGroup - Multi-Specialty
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYGS278OtherOXFORD
NY01783462Medicaid
NYGS278OtherOXFORD
NY01783462Medicaid