Provider Demographics
NPI:1457309130
Name:ODIN, LANNY (MD)
Entity Type:Individual
Prefix:DR
First Name:LANNY
Middle Name:
Last Name:ODIN
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 1:500 N CHENEY ST
Mailing Address - Street 2:
Mailing Address - City:TAYLORVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62568-1139
Mailing Address - Country:US
Mailing Address - Phone:217-777-2020
Mailing Address - Fax:217-777-2023
Practice Address - Street 1:500 N CHENEY ST
Practice Address - Street 2:
Practice Address - City:TAYLORVILLE
Practice Address - State:IL
Practice Address - Zip Code:62568-1139
Practice Address - Country:US
Practice Address - Phone:217-777-2020
Practice Address - Fax:217-777-2023
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036077639207W00000X
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL180031357OtherRAILROAD MEDICARE
ILA10461Medicare UPIN
IL792582Medicare PIN