Provider Demographics
NPI:1497739809
Name:HARDIN, AMY ODOM (MD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:ODOM
Last Name:HARDIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:JOYCE
Other - Last Name:ODOM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 720006
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73070-4006
Mailing Address - Country:US
Mailing Address - Phone:502-381-1446
Mailing Address - Fax:
Practice Address - Street 1:1201 S ADAMS ST
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-5476
Practice Address - Country:US
Practice Address - Phone:405-742-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY367432080P0203X, 208000000X, 207LP3000X
OK32295208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
No207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric Anesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64017031Medicaid
KY64017031Medicaid
KY0773419Medicare PIN
KY0787507Medicare PIN
G54792Medicare UPIN
KYK056040Medicare PIN