Provider Demographics
NPI:1982639738
Name:ODOM, KENNETH FRANKLIN (PA)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:FRANKLIN
Last Name:ODOM
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 729
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36302-0729
Mailing Address - Country:US
Mailing Address - Phone:334-793-2663
Mailing Address - Fax:334-836-2247
Practice Address - Street 1:1500 ROSS CLARK CIR
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-4754
Practice Address - Country:US
Practice Address - Phone:334-793-2663
Practice Address - Fax:334-836-2247
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA.504363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003140733AMedicaid
AL121885Medicaid
GA003140729AMedicaid
AL009940319Medicaid
AL0515580730OtherMEDICARE
AL511-09068OtherBCBS OF AL - HEALTHWEST
AL515-37977OtherBCBS OF AL - RCC