Provider Demographics
NPI:1679994123
Name:ALICIA J. ODUM, MD PA
Entity Type:Organization
Organization Name:ALICIA J. ODUM, MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ODUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-316-1726
Mailing Address - Street 1:PO BOX 8484
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20898-8484
Mailing Address - Country:US
Mailing Address - Phone:202-316-1726
Mailing Address - Fax:
Practice Address - Street 1:1625 PICCARD DR
Practice Address - Street 2:UNIT 402
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-7600
Practice Address - Country:US
Practice Address - Phone:202-316-1726
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-01
Last Update Date:2014-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDO60844173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1457363517OtherINDIVIDUAL NPI