Provider Demographics
NPI:1801860952
Name:ODOM, TODD A (MD)
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:A
Last Name:ODOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:TODD
Other - Middle Name:
Other - Last Name:ODOM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1705 OHIO DR STE 100
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-5256
Mailing Address - Country:US
Mailing Address - Phone:972-612-0430
Mailing Address - Fax:972-612-0529
Practice Address - Street 1:1705 OHIO DR
Practice Address - Street 2:SUITE 100
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-5255
Practice Address - Country:US
Practice Address - Phone:972-612-0430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4400208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX280001123OtherMEDICARE RAILROAD
TX8Z1392OtherBCBS
TX8540N1Medicare ID - Type Unspecified
TX8Z1392OtherBCBS