Provider Demographics
NPI:1659891059
Name:ODOM, MERIDITH NICOLE (MD)
Entity Type:Individual
Prefix:
First Name:MERIDITH
Middle Name:NICOLE
Last Name:ODOM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MERIDETH
Other - Middle Name:
Other - Last Name:FERGUSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 100174
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29202-3174
Mailing Address - Country:US
Mailing Address - Phone:864-512-5910
Mailing Address - Fax:864-512-5915
Practice Address - Street 1:6650 HIGHWAY 81 N
Practice Address - Street 2:
Practice Address - City:PIEDMONT
Practice Address - State:SC
Practice Address - Zip Code:29673-9055
Practice Address - Country:US
Practice Address - Phone:864-512-5910
Practice Address - Fax:864-512-5915
Is Sole Proprietor?:No
Enumeration Date:2017-06-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL41067207Q00000X
SC41067207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC410674Medicaid