Provider Demographics
NPI:1508866773
Name:ODOM, JOHN W (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:W
Last Name:ODOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:PO BOX 919
Mailing Address - Street 2:594 S COLUMBIA DRIVE, STE 100
Mailing Address - City:RINCON
Mailing Address - State:GA
Mailing Address - Zip Code:31326-0919
Mailing Address - Country:US
Mailing Address - Phone:912-826-4057
Mailing Address - Fax:912-826-2853
Practice Address - Street 1:594 S COLUMBIA AVE
Practice Address - Street 2:STE 100
Practice Address - City:RINCON
Practice Address - State:GA
Practice Address - Zip Code:31326-0919
Practice Address - Country:US
Practice Address - Phone:912-826-4057
Practice Address - Fax:912-826-2853
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA033661208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0437236DMedicaid
GACN8505OtherRR MEDICARE
GAF03245Medicare UPIN
GA02BDGWSMedicare ID - Type Unspecified