Provider Demographics
NPI:1578656849
Name:ODELL, GREGORY N (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:N
Last Name:ODELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:157 TOMAHAWK ST
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:10598-6314
Mailing Address - Country:US
Mailing Address - Phone:914-258-0500
Mailing Address - Fax:914-248-5478
Practice Address - Street 1:157 TOMAHAWK ST
Practice Address - Street 2:
Practice Address - City:YORKTOWN HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:10598-6314
Practice Address - Country:US
Practice Address - Phone:914-258-0500
Practice Address - Fax:914-248-5478
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-01
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY229272208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02625625Medicaid
NY229272OtherLIC.
I24960Medicare UPIN
NY229272OtherLIC.