Provider Demographics
NPI:1235291683
Name:ODOM, SYDNEY HOWARD (MD)
Entity Type:Individual
Prefix:
First Name:SYDNEY
Middle Name:HOWARD
Last Name:ODOM
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 72483
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30007-2483
Mailing Address - Country:US
Mailing Address - Phone:770-578-1800
Mailing Address - Fax:
Practice Address - Street 1:1077 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:GA
Practice Address - Zip Code:30650-2073
Practice Address - Country:US
Practice Address - Phone:770-578-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA038896207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA05BDJHF01Medicare ID - Type Unspecified
GAF87675Medicare UPIN