Provider Demographics
NPI:1871012369
Name:ODUM, MATILDA
Entity Type:Individual
Prefix:
First Name:MATILDA
Middle Name:
Last Name:ODUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6426 SEAT PLEASANT DR
Mailing Address - Street 2:
Mailing Address - City:CAPITOL HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:20743-6015
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:27 O ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20001-2378
Practice Address - Country:US
Practice Address - Phone:240-743-6680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-15
Last Update Date:2017-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant