Provider Demographics
NPI:1457627531
Name:ODELL, IAN DOUGLAS (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:IAN
Middle Name:DOUGLAS
Last Name:ODELL
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 YORK ST
Mailing Address - Street 2:ROOM 5040
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-3221
Mailing Address - Country:US
Mailing Address - Phone:203-785-4092
Mailing Address - Fax:
Practice Address - Street 1:333 CEDAR ST BLDG LMP
Practice Address - Street 2:ROOM 5040
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3206
Practice Address - Country:US
Practice Address - Phone:203-785-4092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-22
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT55057207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology