Provider Demographics
NPI:1376771030
Name:ODOM, NATHAN ELDRIDGE (MD)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:ELDRIDGE
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 1:2655 RIDGEWAY AVE
Mailing Address - Street 2:SUITE 420
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-4296
Mailing Address - Country:US
Mailing Address - Phone:585-723-7972
Mailing Address - Fax:585-368-3119
Practice Address - Street 1:12605 E 16TH AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80045-2545
Practice Address - Country:US
Practice Address - Phone:720-848-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-01
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY270558208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400090495/GRP70008AMedicare PIN
NYJ400090496/GRPBA0017Medicare PIN