Provider Demographics
NPI:1457311409
Name:LARBI-ODAM, ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:LARBI-ODAM
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 1:6014 LAKELAND AVE N
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL
Mailing Address - State:MN
Mailing Address - Zip Code:55428-2984
Mailing Address - Country:US
Mailing Address - Phone:612-871-2312
Mailing Address - Fax:612-871-2163
Practice Address - Street 1:6014 LAKELAND AVE N
Practice Address - Street 2:
Practice Address - City:CRYSTAL
Practice Address - State:MN
Practice Address - Zip Code:55428-2984
Practice Address - Country:US
Practice Address - Phone:612-871-2312
Practice Address - Fax:612-871-2163
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN46773207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN660270300Medicaid
MN241815Medicare Oscar/Certification
MNI26327Medicare UPIN