Provider Demographics
NPI:1710235262
Name:MARY ODOFIN MD PC
Entity Type:Organization
Organization Name:MARY ODOFIN MD PC
Other - Org Name:OLAOLUWA ODOFIN MD
Other - Org Type:Other Name
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCANALLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-881-1835
Mailing Address - Street 1:250 CHATEAU DR SW
Mailing Address - Street 2:SUITE 220
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-6436
Mailing Address - Country:US
Mailing Address - Phone:256-881-1989
Mailing Address - Fax:256-319-1368
Practice Address - Street 1:250 CHATEAU DR SW
Practice Address - Street 2:SUITE 220
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-6436
Practice Address - Country:US
Practice Address - Phone:256-881-1989
Practice Address - Fax:256-319-1368
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-15
Last Update Date:2012-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL31854207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty