Provider Demographics
NPI:1508079179
Name:KRESLYN B ODUM & ASSOCIATES, PC
Entity Type:Organization
Organization Name:KRESLYN B ODUM & ASSOCIATES, PC
Other - Org Name:FAMILY EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KRESLYN
Authorized Official - Middle Name:B
Authorized Official - Last Name:ODUM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:478-553-0007
Mailing Address - Street 1:420 W CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:JESUP
Mailing Address - State:GA
Mailing Address - Zip Code:31545-1435
Mailing Address - Country:US
Mailing Address - Phone:478-553-0007
Mailing Address - Fax:478-552-6619
Practice Address - Street 1:420 W CHERRY ST
Practice Address - Street 2:
Practice Address - City:JESUP
Practice Address - State:GA
Practice Address - Zip Code:31545-1435
Practice Address - Country:US
Practice Address - Phone:478-553-0007
Practice Address - Fax:478-552-6619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2242152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA5957030001Medicare NSC