Provider Demographics
NPI:1639114739
Name:ODOM, AMY J (DO)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:J
Last Name:ODOM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 13008
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48901-3008
Mailing Address - Country:US
Mailing Address - Phone:517-364-6253
Mailing Address - Fax:517-364-6208
Practice Address - Street 1:800 E COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:MI
Practice Address - Zip Code:48854-1381
Practice Address - Country:US
Practice Address - Phone:517-244-8940
Practice Address - Fax:517-244-8941
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101015398207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4767919Medicaid
MI4767955Medicaid
MI4780643Medicaid
MI0853311285OtherBCBS INDIVIDUAL PIN
MI4715270Medicaid
MI4767919Medicaid
MI4780643Medicaid
MIC37635014Medicare ID - Type Unspecified
MIC36090055Medicare ID - Type Unspecified
MI4767955Medicaid