Provider Demographics
NPI:1972585669
Name:ODEKIRK, STEVEN W (OD)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:W
Last Name:ODEKIRK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 SUMMERS ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-1239
Mailing Address - Country:US
Mailing Address - Phone:304-343-3937
Mailing Address - Fax:304-344-3957
Practice Address - Street 1:43 EAGLES RD
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-3643
Practice Address - Country:US
Practice Address - Phone:304-253-1210
Practice Address - Fax:304-255-4040
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV837IOD152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0012545000Medicaid
WV0012545000Medicaid
WVT82031Medicare UPIN