Provider Demographics
NPI:1336143163
Name:ODUM, BRETT C (MD)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:C
Last Name:ODUM
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 9
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37662-0009
Mailing Address - Country:US
Mailing Address - Phone:423-857-2066
Mailing Address - Fax:423-857-2070
Practice Address - Street 1:240 MEDICAL PARK BLVD
Practice Address - Street 2:STE 3600
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-7346
Practice Address - Country:US
Practice Address - Phone:423-990-2400
Practice Address - Fax:423-990-2405
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101232193207Q00000X
TNMD 37808207Q00000X
TN37808208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3888335Medicaid
TN3888335Medicaid
TN103I086169Medicare UPIN
H79116Medicare UPIN
TN0281780003Medicare PIN
TN3700592Medicare UPIN
P00060091Medicare PIN
TN0281780001Medicare PIN
VA10123721Medicare ID - Type Unspecified
TNH79116Medicare UPIN
VA10098521Medicare ID - Type Unspecified