Provider Demographics
NPI:1588818603
Name:JAMES C ODOM JR., MD., PC
Entity type:Organization
Organization Name:JAMES C ODOM JR., MD., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:K
Authorized Official - Last Name:DANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-387-0263
Mailing Address - Street 1:PO BOX 1648
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31793-1648
Mailing Address - Country:US
Mailing Address - Phone:229-686-7671
Mailing Address - Fax:229-686-3518
Practice Address - Street 1:416 E MCPHERSON AVE
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:GA
Practice Address - Zip Code:31639-2276
Practice Address - Country:US
Practice Address - Phone:229-686-7671
Practice Address - Fax:229-686-3518
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-17
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00731585AMedicaid
GAG38750Medicare UPIN
GA00731585AMedicaid