Provider Demographics
NPI:1790737997
Name:ODOM, ALBERT E JR (MD)
Entity Type:Individual
Prefix:
First Name:ALBERT
Middle Name:E
Last Name:ODOM
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:803-296-7320
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:300 PALMETTO HEALTH PKWY STE 300
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29212-1763
Practice Address - Country:US
Practice Address - Phone:803-907-7300
Practice Address - Fax:803-907-7309
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2018-04-04
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
SC12029207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC120292Medicaid
SC6129Medicare ID - Type Unspecified
SCD17710Medicare UPIN