Provider Demographics
NPI:1578111571
Name:ODOM, POLYCARP
Entity Type:Individual
Prefix:
First Name:POLYCARP
Middle Name:
Last Name:ODOM
Suffix:
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 1:4050 SMITHS LANDING CT
Mailing Address - Street 2:
Mailing Address - City:ABINGDON
Mailing Address - State:MD
Mailing Address - Zip Code:21009-1259
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4050 SMITHS LANDING CT
Practice Address - Street 2:
Practice Address - City:ABINGDON
Practice Address - State:MD
Practice Address - Zip Code:21009-1259
Practice Address - Country:US
Practice Address - Phone:443-402-0722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-03
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR4455253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care