Provider Demographics
NPI:1275557886
Name:ODOM SPORTS MEDICINE, P.A.
Entity Type:Organization
Organization Name:ODOM SPORTS MEDICINE, P.A.
Other - Org Name:ODOM HEALTH & WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:H
Authorized Official - Last Name:ODOM
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:952-224-1919
Mailing Address - Street 1:10653 WAYZATA BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-1543
Mailing Address - Country:US
Mailing Address - Phone:952-224-1919
Mailing Address - Fax:
Practice Address - Street 1:6545 FLYING CLOUD DR STE 201
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-3356
Practice Address - Country:US
Practice Address - Phone:952-224-1919
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Single Specialty