Provider Demographics
NPI:1790901957
Name:ODOM, JAMES F (PAC)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:F
Last Name:ODOM
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2041 MESA VALLEY WAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-6828
Mailing Address - Country:US
Mailing Address - Phone:770-944-1100
Mailing Address - Fax:770-941-7227
Practice Address - Street 1:2041 MESA VALLEY WAY
Practice Address - Street 2:SUITE 100
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-6828
Practice Address - Country:US
Practice Address - Phone:770-944-1100
Practice Address - Fax:770-941-7227
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2011-05-20
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA005030363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA898561166GMedicaid
GA898561166HMedicaid
GA898561166FMedicaid
GA898561166IMedicaid
GA898561166FMedicaid