Provider Demographics
NPI:1831672096
Name:ODOMS, RAVEN (RT)
Entity Type:Individual
Prefix:
First Name:RAVEN
Middle Name:
Last Name:ODOMS
Suffix:
Gender:F
Credentials:RT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 HIGHWAY 418 E
Mailing Address - Street 2:
Mailing Address - City:SILSBEE
Mailing Address - State:TX
Mailing Address - Zip Code:77656-3729
Mailing Address - Country:US
Mailing Address - Phone:409-386-1200
Mailing Address - Fax:409-386-1219
Practice Address - Street 1:280 HIGHWAY 418 E
Practice Address - Street 2:
Practice Address - City:SILSBEE
Practice Address - State:TX
Practice Address - Zip Code:77656-3729
Practice Address - Country:US
Practice Address - Phone:409-386-1200
Practice Address - Fax:409-386-1219
Is Sole Proprietor?:No
Enumeration Date:2018-09-12
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX924752471C3402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiography