Provider Demographics
NPI:1467413674
Name:ODEN, JON DAVID (MD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:DAVID
Last Name:ODEN
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 1:1 CHILDRENS WAY # 653
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72202-3500
Mailing Address - Country:US
Mailing Address - Phone:501-686-8000
Mailing Address - Fax:501-526-6562
Practice Address - Street 1:1 CHILDRENS WAY # 653
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72202-3500
Practice Address - Country:US
Practice Address - Phone:501-686-8000
Practice Address - Fax:501-526-6562
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK56442080P0205X
ARE-91632080P0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8C0235Medicare ID - Type Unspecified
H97270Medicare UPIN
TX166468201Medicaid