Provider Demographics
NPI:1225296478
Name:ODDLEIFSON, ERIC MARTIN
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:MARTIN
Last Name:ODDLEIFSON
Suffix:
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 1:484 MAIN ST
Mailing Address - Street 2:EASTER SEALS MA
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01608-1893
Mailing Address - Country:US
Mailing Address - Phone:180-024-4275
Mailing Address - Fax:
Practice Address - Street 1:484 MAIN ST
Practice Address - Street 2:EASTER SEALS MA
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608-1893
Practice Address - Country:US
Practice Address - Phone:180-024-4275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-23
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7626246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other