Provider Demographics
NPI:1437180072
Name:ODOM-AUSTIN, ANGELA D (MD)
Entity Type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:D
Last Name:ODOM-AUSTIN
Suffix:
Gender:F
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 1230
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23661-0230
Mailing Address - Country:US
Mailing Address - Phone:757-247-1111
Mailing Address - Fax:757-825-5740
Practice Address - Street 1:1140 S VIENNA ST
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-5834
Practice Address - Country:US
Practice Address - Phone:318-224-7190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010471202080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6754406Medicaid
LA2505637Medicaid
LA2505637Medicaid