Provider Demographics
NPI:1568754646
Name:ODOM, RONALD HUNTER JR
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:HUNTER
Last Name:ODOM
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 W 3RD AVE
Mailing Address - Street 2:STE 101
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31701-1985
Mailing Address - Country:US
Mailing Address - Phone:229-312-5800
Mailing Address - Fax:229-889-7055
Practice Address - Street 1:417 W 3RD AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31701-1943
Practice Address - Country:US
Practice Address - Phone:229-312-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-09
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN188403367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered