Provider Demographics
NPI:1639153257
Name:ODOM, STEPHEN RAY II (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:RAY
Last Name:ODOM
Suffix:II
Gender:M
Credentials:MD
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Mailing Address - Street 1:110 FRANCIS ST
Mailing Address - Street 2:LMOB 3A
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-5501
Mailing Address - Country:US
Mailing Address - Phone:617-632-9786
Mailing Address - Fax:617-632-0886
Practice Address - Street 1:14 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28803-2493
Practice Address - Country:US
Practice Address - Phone:828-252-3366
Practice Address - Fax:828-258-0891
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2018-05-16
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Provider Licenses
StateLicense IDTaxonomies
CO43996208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO33452555Medicaid
COP00255737OtherMEDICARE RAILROAD CARRIER
CO840255530039OtherROCKY MTN HEALTH PLANS
COI43378Medicare UPIN
COC803598Medicare PIN