Provider Demographics
NPI:1265520662
Name:ODOM, MARTY WAYNE (MD)
Entity type:Individual
Prefix:DR
First Name:MARTY
Middle Name:WAYNE
Last Name:ODOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1029 MEDICAL CENTER CIR STE 204
Mailing Address - Street 2:
Mailing Address - City:MAYFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42066-1189
Mailing Address - Country:US
Mailing Address - Phone:270-251-4545
Mailing Address - Fax:270-251-4425
Practice Address - Street 1:1029 MEDICAL CENTER CIR STE 204
Practice Address - Street 2:
Practice Address - City:MAYFIELD
Practice Address - State:KY
Practice Address - Zip Code:42066-1189
Practice Address - Country:US
Practice Address - Phone:270-251-4545
Practice Address - Fax:270-251-4425
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2022-08-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME82596207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP01109190OtherR&R MEDICARE
FL266818100Medicaid
FLU0695XMedicare PIN