Provider Demographics
NPI:1598941619
Name:ODEN, PAUL LAVERNE (DC)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:LAVERNE
Last Name:ODEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:ELDON
Mailing Address - State:MO
Mailing Address - Zip Code:65026-1830
Mailing Address - Country:US
Mailing Address - Phone:573-392-6621
Mailing Address - Fax:573-392-4127
Practice Address - Street 1:315 E 3RD ST
Practice Address - Street 2:
Practice Address - City:ELDON
Practice Address - State:MO
Practice Address - Zip Code:65026-1830
Practice Address - Country:US
Practice Address - Phone:573-392-6621
Practice Address - Fax:573-392-4127
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-18
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO004991111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
T73820Medicare UPIN