Provider Demographics
NPI:1942291349
Name:ODEGAARD, MARY E (MD)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:E
Last Name:ODEGAARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:E
Other - Last Name:LAFLAMME
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:111 GROSSMAN DR
Mailing Address - Street 2:FAMILY MEDICINE
Mailing Address - City:BRAINTREE
Mailing Address - State:MA
Mailing Address - Zip Code:02184-4997
Mailing Address - Country:US
Mailing Address - Phone:781-849-2560
Mailing Address - Fax:781-849-2529
Practice Address - Street 1:111 GROSSMAN DR
Practice Address - Street 2:FAMILY MEDICINE
Practice Address - City:BRAINTREE
Practice Address - State:MA
Practice Address - Zip Code:02184-4997
Practice Address - Country:US
Practice Address - Phone:781-849-2560
Practice Address - Fax:781-849-2529
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA81548207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
080078724OtherRR MEDICARE
081548OtherTUFTS
MAODJ16519OtherBCBS
MA70989OtherHPHC
3552899OtherCIGNA
MA3155102Medicaid
081548OtherTUFTS
MA70989OtherHPHC